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or higher is a red flag. It doesn't necessarily exclude the patient, but does warrant further examination. We'll also instantly exclude a patient with a heart condition who might require a higher level of peri- operative care, an extended hospital stay or poten- tial readmission. Trying to comb out exactly how bad is too bad? is the next frontier for our practice. We're currently looking at ways to somehow increase safety in order to admit riskier patients. But if you're just starting out with outpatient total shoulders, you likely want to err more on the side of caution — at least initially. • Regional blocks. Place a heavy emphasis on regional anesthesia for your shoulder patients. Compared to 15 or 20 years ago, anesthesiologists have gotten much more efficient at perform- ing regional, and the effective- ness and duration of these blocks are much better. It's become much more streamlined. We've been proactive in terms of trying to provide a multifaceted approach to perioperative pain control. We generally combine sedation with an interscalene regional anesthetic block in order to help lower morphine equivalents postoperatively. The feedback from patients is very positive — largely due to education on the front end. There's been so much publicity about the opioid crisis, and peo- ple want to avoid narcotics and opioids, so they buy into the mul- timodal approach much more readily than they did in the past. That's been a huge improvement in the last two to three years. With combined anesthesia tech- niques, I've been able to do shoul- der surgeries more safely, with reduced usage of opioids and other narcotic medications. • Bundled payments. Over the last three to five years, we've been transitioning to a bundled payment program for our total joints, which I view as a win for everyone. The patient stays away from the hospital where COVID-19 is being treated. From a cost 2 4 • S U P P L E M E N T T O O U T P A T I E N T S U R G E R Y M A G A Z I N E • S E P T E M B E R 2 0 2 0 The coronavirus has shown me that telehealth absolutely has a role to play in total shoulder procedures. When the pandemic hit and we had to close our practice, our marketing and quality teams paired with our senior leadership to launch virtual care in a week. We'd never done it before. My patients come from different parts of Minnesota and adjoining states. Being able to provide continuity of care without patients having to travel, masked, for an in-person visit simply to review X-rays has been really helpful. On the physical therapy rehab side, we heavily used telehealth when our facilities were closed from March to May due to COVID-19. Will the govern- ment and private insurers continue to cover telemedicine going forward in orthopedics? That remains to be seen. Our group is going back to more in-person visits, but I think for the right patient at the right stage of their recovery, telehealth, even just for rehab and follow-up visits, can work really well. —Gregory N. Lervick, MD Pandemic Highlights Potential of Telehealth HOUSE CALL Gregory Lervick, MD, met with patients remotely when the coronavirus outbreak closed his office. COVID-19