INTRODUCTION
The medical field is constantly evolving, making it essential for healthcare professionals to remain updated regularly. Continuing Medical Education (CME) is a means of knowledge upgradation to ensure provision of evidence-based patient care1. With technological advancement, telemedicine is a platform to deliver CME remotely. Telemedicine as defined by the World Health Organization as the delivery of services by health professionals, using information and communication technologies for the purposes of diagnosis, treatment, research and evaluation. Furthermore, it is known to facilitate the continuing education of health professionals, when distance is a critical factor2.
CME is a means of discussing emerging clinical guidelines, treatment protocols and new medical technologies3. In-person CME is challenging due to the inflexible schedule of healthcare workers as well as the financial implications associated with travel, accommodation and event fee4. CME provided online via telemedicine mitigates these challenges and also has a wider reach5. In fact, many health systems now use digital technology to not just provide CME remotely but also to provide healthcare services remotely, helping reduce disparities6.
Telemedicine is not new to Bhutan. Pilot projects of telemedicine initiated earlier, such as the pilot tele-radiology project linking Bumthang Hospital with the national referral hospital in Thimphu, could not be sustained. The probable factors for failure include slow internet speed, erratic power supply and lack of skilled human resources, limited financial support, inadequate infrastructure, poor communication systems and time constraints amongst clinicians. These challenges have confined telemedicine to an experimental phase in Bhutan. However, telemedicine made a comeback during the COVID-19 pandemic where it was used for both clinical and educational purposes. We describe the collaboration of the Central Regional Referral Hospital (CRRH) with the World Telehealth Initiative (WTI) in implementing telehealth services at CRRH.
Collaboration with the WTI network
In line with the directives from the National Medical Services (NMS), CRRH collaborated with WTI to establish a telehealth initiative in the hospital. NMS, established on 9 January 2023 as part of the health sector transformation of Bhutan’s Ministry of Health, aims to provide stewardship for clinical services in the country. WTI, a global non-profit organization, supports underserved areas by providing telemedicine consultations and continuous professional development via its network of global medical experts7. As of October 2024, WTI is operational in 17 countries, supporting over 1,400 healthcare professionals across 50 specialties to deliver advanced medical care7.
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Through this collaboration, CRRH received telehealth equipment, access to a cloud-based network, and implementation and operational support from the WTI. Leveraging WTI’s platform, healthcare professionals of CRRH are connected with clinical experts from around the world. As the country’s second busiest tertiary hospital, CRRH serves all 20 districts and is the referral center for five central districts. Despite offering multiple specialty services, some cases still require consultation with sub-specialists at the National Referral Hospital in Thimphu or outside Bhutan. Using the telemedicine device, doctors at CRRH can consult experts elsewhere and also request for bedside patient consultations. Such initiatives help patients receive timely healthcare services while reducing referral related costs.
Timeline of WTI activities
The first collaborative meeting between CRRH and WTI was held on 20th September, 2023 via Zoom. Areas of collaboration with desired benefits of telemedicine facilities were finalized. In addition, WTI guided CRRH healthcare professionals through registration on the WTI platform and provided a live simulation training from their US-based Technical Innovation Center, using the Provider Access Software application for patient care and professional development.
Training began on 28 November, 2023 and over the subsequent few months, 32 doctors, including medical specialists and medical officers were trained to use the WTI network, each receiving a personalized 30-minute session.
CRRH received the WTI device from California on
January 2024 and it was officially launched on 28 March, 2024, with WTI personnel joining virtually. During the launch, WTI reaffirmed their commitment to provide CME trainings and support patient consultations via their network of experts.
The first CME on dialysis guidelines was conducted by a US-based nurse specialist on 24 May, 2024 (Figure 1). A CME series on Point of Care Ultrasound (POCUS) began on 18 September, 2024, led by telehealth specialists from Orlando Health, Florida. Over weekly sessions, doctors in CRRH learnt basic and advanced POCUS techniques, as an adjunct to facilitate diagnosis and management. An Emergency Physician from CRRH assisted participants on-site (Figure 2). Through this project, CRRH received a ButterflyiQ ultrasound probe, enabling Orlando Health experts to view live scans and provide real-time guidance remotely. Two-way video teleconferencing via the WTI device enabled interactive, face-to-face-style training despite the distance.
Fig 1: Healthcare professionals of CRRH attending CME conducted by WTI network, 2024.
The POCUS training concluded on 6 November, 2024 with an Objective structured Clinical Exam (OSCE) conducted amongst participants. During the OSCE, participants performed scans on specific anatomical regions while experts from Orlando Health assessed their technique and image quality. Feedback and results were provided at the end of session, with experts approving the adequacy of the scans. Upon completion of the session, the ButterflyiQ ultrasound device was handed over to the Department of Emergency Medicine at CRRH for clinical use. Doctors continue to receive expert feedback and guidance on real patient scans. As of 9 February 2025, WTI has conducted eleven CME trainings across various specialties (Table 1). CRRH has not yet used telemedicine for patient consultations. Efforts are currently underway to expand telemedicine activities to include case consultations with experts both in-country and worldwide.
Fig 2: Doctors of CRRH practicing POCUS while experts from Orlando Health oversee the session via the WTI device, 2024.
Impact of WTI Network
Although there is no objective assessment of the impact of CME through WTI, anecdotal reports suggest significant benefits in enhancing knowledge and skills of healthcare providers, on evidence-based medical and surgical care.
The most impactful initiative to date has been the CME series on POCUS. Covering topics such as basic and organ specific ultrasonography, protocols for shock and hypotension, focused assessment with sonography for HIV associated tuberculosis (FASH), and ultrasound guided nerve blocks and vascular access, doctors at CRRH now apply POCUS in routine diagnostics. The ButterflyiQ ultrasound device provided by WTI is actively utilized in the emergency department.
Telehealth enabled CME across various specialties has connected CRRH healthcare professionals with the global experts, fostering skill development and promoting best practices, which ultimately enhances patient care. As a teaching hospital under the Khesar Gyalpo University of Medical Sciences of Bhutan, CRRH also trains nurses, technicians, interns and residents. The WTI telemedicine network helps faculty stay updated with current clinical practices, improving the quality of both patient care and student training during clinical attachments.
Telemedicine has the potential to help the country achieve the Sustainable Development Goal of Universal Health Coverage by enhancing access to effective, safe and affordable healthcare services8. Telemedicine can enable patients to receive quality healthcare without having to travel to far-flung centers.
Initiatives of WTI also helped the healthcare professionals in the hospital to explore the use of WTI device, which is a new and advanced technology for patient care. network, 2024 – February, 2025 Telemedicine facilities are powerful tools in healthcare system that allow healthcare professionals to connect and learn from global experts within the click of buttons. Such practice is costeffective, help healthcare professionals learn at their convenience and leverage technological advancement for patient care5,6,9,10.