What is the optimal method to order baseline laboratory tests for a telehealth patient initiating antipsychotic therapy, and should I establish an account with Quest Diagnostics?

Optimal Laboratory Ordering for Telehealth Antipsychotic Initiation

Yes, establish an account with Quest Diagnostics or a similar national laboratory service to enable secure, efficient ordering of baseline metabolic monitoring labs for patients initiating antipsychotic therapy via telehealth. 1

Infrastructure Setup for Laboratory Ordering

Create a direct account with a national laboratory service (Quest Diagnostics, LabCorp, or similar) that allows you to electronically order tests and receive results through secure, encrypted channels. 1 This approach addresses the fundamental challenge of telehealth practice where you cannot rely on a hospital's virtual private network for laboratory requisitions. 1

Practical Implementation Steps:

• Establish provider accounts with one or two major national laboratory chains that have widespread geographic coverage to accommodate patients across different locations 1
• Use secure encrypted email or integrated platforms (such as Doximity) to send laboratory requisitions to patients when they are in different geographical areas 1
• Ensure HIPAA-compliant data transmission for all laboratory orders and results, avoiding unsecured communication channels 1
• Integrate laboratory ordering into your electronic health record if possible, or maintain a secure system for tracking ordered tests and pending results 1

Required Baseline Laboratory Tests for Antipsychotic Initiation

The specific baseline tests depend on which antipsychotic you're prescribing, but the following framework applies:

For Aripiprazole:

• Fasting blood glucose (mandatory baseline) 2
• Hemoglobin A1c (as alternative or supplement to fasting glucose) 2
• Complete blood count with differential (within 1-2 months of starting) 2
• Liver function tests (ALT, AST) particularly if hepatotoxic medication history exists 2

For Clozapine (Higher Metabolic Risk):

• Fasting blood glucose or HbA1c (mandatory per American Diabetes Association) 3
• Fasting lipid panel (baseline requirement) 3
• Body mass index and waist circumference (document baseline) 3
• Blood pressure (baseline measurement) 3
• Absolute neutrophil count (mandatory for clozapine registry) 3

For Risperidone in Adolescents:

• Hepatic transaminases (baseline liver function) per American Academy of Child and Adolescent Psychiatry 4
• Complete blood count (screen for agranulocytosis/leukocytopenia risk) 4
• Electrocardiogram (assess QT interval at baseline) 4
• Renal function tests (baseline assessment) 4

Follow-Up Monitoring Schedule

Establish systematic protocols for result review and follow-up before initiating treatment. 1

Timing of Follow-Up Labs:

• First follow-up: 1-2 months after antipsychotic initiation for fasting glucose, CBC, and liver enzymes 2
• Subsequent monitoring: Every 3-4 months for routine metabolic surveillance 2
• For clozapine specifically: 12-16 weeks after initiation, then annually for glucose screening 3
• Higher-risk patients (pre-existing diabetes, metabolic syndrome) require monthly monitoring for the first 3 months 2

Critical Workflow Considerations

Result Management System:

Create a reliable system to ensure laboratory results reach you and are reviewed before the next clinical decision point. 1 The European Association of Urology emphasizes that telehealth teams must ensure complementary test results are available before making clinical decisions. 1

• Designate a secure portal or email where laboratory results are automatically sent 1
• Schedule follow-up telehealth visits only after confirming results are available for review 1
• Send result reports to patients through secure patient portals when appropriate 1
• Document all laboratory orders and results in your clinical record with the same rigor as face-to-face consultations 1

Common Pitfalls to Avoid:

• Never compromise on baseline testing due to telehealth limitations—the same confirmatory testing principles apply equally to all care settings 1
• Avoid treatment shortcuts without appropriate laboratory confirmation, as this creates a two-tiered quality system 1
• Don't defer urgent laboratory tests excessively; consider clinical urgency, patient age, and health status when scheduling 1
• Ensure patients understand how to access laboratory facilities in their geographic area before ordering tests 1

Geographic and Access Considerations

When patients are located in different geographic areas, coordinate with local laboratory facilities or mobile phlebotomy services that can draw blood and send samples to your contracted laboratory. 1 Send requisitions via secure encrypted email with clear instructions on which laboratory location the patient should visit. 1

For patients with limited mobility or in rural areas, explore whether your contracted laboratory service offers at-home phlebotomy services, which many national chains now provide. 1

Quality Assurance

The American Academy of Pediatrics emphasizes that all quality assurance protocols apply equally to telehealth and in-person encounters. 1 This means your laboratory monitoring for antipsychotic therapy must meet the same standards regardless of visit modality. Physician telehealth services can properly oversee laboratory testing when using established protocols and standards. 5