The Technical Performance and Clinical Feasibility of Telecolposcopy
Discussion
The telecolposcopy system captured the SCJ extremely well. Our study had an interobserver correlation of SCJ visualization similar to that seen for comparisons between different readers of the same cervigram image.26,27 To compare between review and remote sites, the colposcopist at site 1 determined the impression while at the colposcope, and the colposcopist at the review center used the same patient’s digital image. The interobserver agreement for our colposcopic image versus digital image colposcopic impressions (86%) was higher than that when both colposcopic impressions were read from colpophotographs.28 Our interobserver correlations between the colposcopic impression and histology agreed with others’ correlations for exact histologic agreement29,30 (66%) references and was within 1 degree of disease severity (86%) reference number.31 The difference in interobserver agreements for the colposcopic impression and histology correlates reflects the difficulty in determining normal metaplasia from low-grade disease, a more difficult distinction than that between normal and high-grade or cancer disease.8,28
Implementation of any organizational change within a medical office can often be difficult. It is more easily accepted when the organizational change is part of a clinical study.32 Both remote sites adopted the full telecolposcopic system (patient history data and image collection) after our study, because the teaching system, consultation reports, and record documentation were superior to the previous systems. Our study initially gave them the support and structure to use the telecolposcopic system. Implicit in adopting a new computerized system is the availability of someone to troubleshoot software and hardware problems. A remote telecolposcopic system requires that the main technical support comes from the review center, with onsite local technical help available, if necessary. In our study, technical help provided by the review center successfully kept the remote telecolposcopy systems functional with minimal effort.
More than two thirds of the women in our study were referred from their usual site of gynecologic health care to the colposcopist, and most traveled 25 miles or less to keep the appointment. Other studies have shown that women will drive more than 200 miles to participate in health care screening activities.33 We have shown that when given the choice of a local provider with telecolposcopy access or driving more than 25 miles for an experienced examination, 95% of the women preferred to receive their care from a local colposcopist. This implies that for women in rural communities, local access to colposcopy with telecolposcopic links is preferred to traveling to a distant center of colposcopic excellence. Future efforts at increasing access to colposcopy for women should be directed toward local telecolposcopic connections with a regional center of excellence for image referral.
Conclusions
We have demonstrated that telecolposcopy is feasible, can be implemented in mountainous rural office sites, and is acceptable to the women undergoing the examination. To move from a demonstration project to a regional telecolposcopic network, telemedicine standards established for all telespecialties must be followed, including appropriate licensure and encryption standards.34 Following these standards, the telecolposcopic network has the potential to offer increased access to and improved accuracy of colposcopic services. In addition, as an educational tool telecolposcopic images can be used for medical student, resident, and continuing medical education instruction, as well as direct patient education. Colposcopic training within an obstetrics and gynecology or family medicine residency training program occupies a small proportion of the curriculum. Telecolposcopy can be used to assist residents and other health care providers located at remote sites by providing access to experienced faculty and a large database of patients to review. The digital cervical images, if focused correctly, can provide more detail than the current hand-drawn documentation, which may lead to better cytologic, colposcopic, and histologic correlation.9
Colposcopists who as individuals perform a small number of colposcopies can gain knowledge from communicating between practices with the other single colposcopists through this network. They can all then anonymously compare their diagnoses with the actual biopsy result as a voluntary quality assurance and improvement program. This benchmarking can provide the groundwork for national colposcopic standards, as has been done in other countries35,36 and in the United States for mammographic image and histology correlations.37 The telecolposcopic system could focus on increasing access to colposcopy and on improving colposcopic pattern recognition skills so that high-grade disease would be targeted for treatment, and the overtreatment of low-grade disease would be avoided.
Acknowledgments
The New Hampshire Health Care Transition Fund Grant 98136, the Koop Institute, the Robert Wood Johnson Foundation, and the Division of Gynecologic Oncology, Dartmouth Medical School, have supported this work.
