BACKGROUND: The purpose of our study was to demonstrate the technical performance and clinical feasibility of a telecolposcopic system through assessment of image transmission veracity, ease of office system implementation, and the patient’s acceptance of the electronic image transmission.
METHODS: We used a telecolposcopic system incorporating a custom software package that integrated patient history, current gynecologic status, epidemiologic risk factors, and colposcopic images for local medical documentation and transmission. Satisfaction questionnaires were developed to measure ease of implementation at the remote sites and the patients’ acceptance of telecolposcopy.
RESULTS: Seventy-nine women participated in our trial. From 3 to 20 images were captured for each woman, documenting cervical squamous intraepithelial lesions and vaginal and vulvar diseases. All images were received without distortions in color, size, or orientation. With complete visualization of the squamocolumnar junction there was an 86% agreement between the remote and review sites (k=.533, P=.019). The interobserver agreement for colposcopic impressions was 86% (k=.684, P <.001), and for colposcopic impressions with histology within one level of disease severity,86%(k=.78,P<.001).Col-poscopists’ and patients’ satisfaction with telecolposcopy was excellent. More than 95% of the women stated that they would rather have their colposcopy locally with electronic transmission if an experienced colposcopist were more than 25 miles away.
CONCLUSIONS: The telecolposcopic system described in our study is technically feasible, can be implemented in an office system with limited technical support, and is preferred by women who have to travel many miles to receive referral health care.
The goal of colposcopy is to identify women with high-grade disease through appropriately targeted biopsy and to correlate the cytologic-colposcopic-histologic results into a cohesive and appropriate management strategy. Approximately 80% of gynecologists and 10% of family physicians in New Hampshire currently provide access to colposcopy. These physicians have a desire to network to improve their colposcopic accuracy.1 Little work has been published either to define adequate access to colposcopy for any population of women or to improve colposcopic accuracy. Active maintenance and improvement of colposcopic skills are important, because they deteriorate after initial training. Several studies have reported lower than 50% sensitivity for detecting the quadrant of the cervix where the cervical intraepithelial neoplasia (CIN) is present.2-4 “See and treat” electrosurgical loop excision procedures have resulted in up to 50% of the specimens being histologically normal.5-9 These high rates of inaccuracy happen because of colposcopists’ inability to distinguish normal from abnormal cervical tissue. Without a dedicated desire to maintain and improve their skills, colposcopists may inadvertently overtreat women on the pretext of preventing cervical cancer.
One potential method for improving colposcopic recognition skills is the development of a network of telecolposcopists who share patient histories, colposcopic images, and histology correlations on a routine basis. Before determining whether this network would improve colposcopic care, it must first be shown that telecolposcopic images can be transmitted to and recognized accurately at the reception site.
Radiologists, dermatologists, pathologists, and psychiatrists10-13 have accurately relayed image transmissions. The fields of otorhinolaryngology, ophthalmology, cardiology, pulmonology, and emergency medicine have also reported telemedicine capabilities during the past few years. Teleobstetrics has demonstrated the feasibility of remote fetal ultrasonography and home monitoring of uterine activity accurately portraying fetal anomalies and uterine contractility.14-17 Colposcopy provides similar visual information about a woman’s gynecologic health. The parameters for successful telemedical image interpretation have been established for these other fields by studying the correlation between the telemedicine image and the conventional diagnostic modality.11-13,18-23
The purpose of our project was to demonstrate the technical performance and clinical feasibility of a low-end telecolposcopic system in a rural mountainous environment. Our primary goal was to determine if the transmission of colposcopic images was technically feasible and would be accurately received in an environment where the ground terrain prohibits radio wave and some satellite transmissions. Our secondary goals were to determine whether the telecolposcopy system could be incorporated into a busy medical office with minimal disruption and to determine how it affects the woman’s perceptions of the colposcopic examination. We included several questions to determine how far each woman was willing to travel to see the expert in person rather than participate in telecolposcopy.
Methods
The Review and Remote Site Selection
The review site was based at the Dartmouth Hitchcock Medical Center (DHMC), where an experienced colposcopist reviewed all images. Two remote sites were chosen for this feasibility study: The first site was a single-physician practice located in rural New Hampshire; the second site was an urban residency training clinic remote from DHMC.*
The telecolposcopic system was designed to maximize the quality of digitized images viewed during the examination and deliver those images electronically to the review center. The computer system was installed by the computer support personnel at each remote site in less than 2 hours, and included a brief introduction to the software and 3 to 5 trial runs with mock patients. Computer support personnel visited both sites one additional time during the study to answer software, hardware, and transmission questions. Our study received approval from the Committee on Protection of Human Subjects from Dartmouth Medical School.