Understanding Decoction Service: The "must-knows" about us cooking your patients' herbs

Patient compliance is often a challenge when prescribing herbal medicine. Cooking herbs into medicinal tea can be time-consuming for people and confusing for patients to navigate on their own. Even patients with the time and intention find themselves forgetting to prepare herbs or using methods that don’t yield the most potent solution. Using filtered and mineralized water, Root & Branch will cook your patient’s herbs for them to make sure they get the most potent brew to help resolve their ailments.

SUPER IMPORTANT THINGS TO REMEMBER ABOUT DECOCTION SERVICE:

1.  Because of food safety concerns with shipping, decoction Service is only available for patients who are able to come to the pharmacy in person to pick up their cooked herbs.

2. R&B cooks  1 day’s herbs, written as 1 bag of herbs. into 16oz of finished decoction. Dosing therefore is usually 8oz (1 cup) per dose, 2 times per day. Exact volume will vary slightly depending on the herbs in a formula and the number of days being cooked. IF YOU NEED EXACT VOLUMES FOR YOUR PATIENTS, you may want your patients to cook their herbs at home.

3. In order to guarantee that decoctions are fresh and safe to consume, R&B CANNOT decoct more than 7 days worth of herbs at a time (i.e. no more than seven jars of decoction at a time).

4. From the time payment is received for herbs, it usually takes 2-2.5 hours for the herbs to be cooked, cooled, and packaged. Please advise your patients accordingly. As with all herbs, they will receive a text notification when their herbs are ready for pick-up.

5. Decoction service costs $5.00. We try to keep these fees low so that more people can take advantage of this service.

We use electric pressure cookers to decoct herbs in our shop. We have experimented extensively with cook times, temperatures, and water levels to create a process that produces potent extractions. We are able to maintain the volatile components of short boil herbs by condensing them back into the decoction or by using a more traditional “add at the end” method. Please specify “add at the end” when building your formula if that is your preference. All of our decoctions leave the shop in sanitized, reusable, tempered-glass jars that keep those decoctions food safe in the refrigerator for as many as 10 days.  Please adhere to the “Best-Buy” date in your patient’s herb packet.

Other cooking services:

We can cook herbs into smaller quantities for people who don’t necessarily want to take 16oz of cooked herbs per day. For example, for several pediatric patients we cook 7 days of herbs into 16oz. This involves more time than standard decoction service (as many as 4 hours total) and that information should be communicated to the patient. If you would like us to do some sort of special cook down you can write that information into the “Special Instructions” section at the bottom of the formula creation screen and we will see the information. Those special instructions should read something like “please cook all 7 bags down into 16oz of decoction” If it is something that we haven’t done for you before or that you’re not sure we can can actually do, give us a call at 971-288-5939, and we can chat about how to make your request into reality.

Refills: Strategies to Keep your Patient's taking their Medicine

We know that patients are likely to have to take their herbs for more than just one round of administration. We also know that sometimes it takes a little while to get the formula just right for a particular patient and their pattern. So when you are designing your formulas and thinking about how long you want a patient to take a formula, spend some time thinking about how many times you might want the patient to refill their herbs.

Picking your refill settings for any formula is accomplished in the formula builder window toward the bottom of that screen. There are a lot of fields to consider when building a formula but making sure you get this one just the way you want will mean that your patients can get the refills they need with as little delay as possible. Let’s take a look at that part of the screen:

Here you can see three essential fields for refills:

1. No. of Refills Allowed (how many refills do you want authorized for this formula?)

2. Days allowed between refills (Do you want them to be able to do multiple refills at once or have to wait a number of days between?)

3. Refill Expires on: (When do you want these authorized refills to expire?)

In order for your refill settings to work correctly, you must have something in each of these fields. Leave one blank and the whole thing falls apart.

As you can see in this image, I have set my refill settings to auto-populate 3 refills, 0 days between refills (meaning that if a patient wanted to refill all three refills at once, like they might if they were going a trip and needed lots of herbs, then they could), and 120 days expiration. The expiration on this screen displays as a specific date but when you create your defaults, it asks for a number of days.

You can set up your defaults by clicking on the settings link on the left side of the screen and then choosing refill settings. You can set different settings for granule formulas, raw/bulk formulas, and for patents. Or you can use a universal setting as I have here for all formulas.

Why bother with a universal setting?

I think having those fields autofilled makes my prescribing faster since I usually want my patients to be able to refill their herbs. And if I want to change the specifics on any given formula, then I make those changes in live time, say change the number of refills from 3 to 1 for example. Importantly, if I’m not fully on my game and forget to look at refills in detail, I know that my patients will have standard refills added to their formula at a level that I am generally comfortable with.

What if I don’t put any refill settings in place?

If you haven’t authorized any refills for a given formula, we won’t be able to refill that formula for your patient without your express permission. Even if you spoke with your patient about refills, even if they have had refills in the past, and even if they are certain that it’s ok to refill their herbs, we can’t do it without your permission, and we all know that it’s not always easy to get a practitioner on the phone when you need them ASAP. So please please please, consider your refill settings for each formula you build so that we can efficiently get your patients the herbs that they need.

The Herbal Pharmacy Process: Steps to maximize you and your patients' experience at Root & Branch

Creating new habits and getting comfortable with new systems can sometimes be challenging. At Root & Branch, we want you to feel comfortable with HerbaScript™, our online ordering system so that you can write formulas efficiently and effectively. So I wanted to highlight a few key items to getting started with HerbaScript™

Pharmacy Essentials

1. Root & Branch only prepares herbs that have been paid for
   In order to keep costs as low as possible and to minimize waste, our pharmacy only prepares herbs for which payment has been received. Fortunately HerbaScript™ will send a payment link via text and/or email to your patient so that they can pay for those herbs. As soon as payment is received, we will get working on the formula. If you would like your patient’s herbs to be made as soon as the order has been placed, you can always use the Vouch System in your practitioner settings to make that happen. More on vouching in future posts.

2. Preparation times may vary
   Depending on how many formulas the pharmacy is processing at any one moment, the time it takes for your patient’s herbs to be prepared can vary. This variation is especially true for decoction, grinding, and encapsulation services. If you or your patient would like the most accurate estimate of preparation time, it is always best to call us directly (971) 288-5939

3. We Will Make It EXACTLY As You Submit It

   We prepare a lot of our herbs ahead of time to maximize their use like crushing zhi zi or splitting xing ren but other herbs can be prepared in a variety of ways depending on what you want to achieve with your formula. So you need to tell us about any special instructions you want for any particular ingredient. Use the “Special Instructions” at the end of the formula build screen to tell us.

   A lot of the folks that work in our pharmacy are Chinese Medicine practitioners themselves, but not everyone is. So we train our staff to make your formula exactly as you send it. Want your Gui Zhi short-boiled? Then make sure to choose “add at the end” at the end of the line where you added that herb into your formula. Want the Fu Zi preboiled? Make that selection. Want us to crush the rou gui into powder? Type that into the special instructions section.

4. More information is better
   In all cases, communicating more and detailed information to the pharmacy is best. Use the special instructions section at the end of the formula builder to tell us what you need or want, and if in doubt, give us a call (971) 288-5939. If we don’t have essential information about your formula like dosage (number of bags or jars per day for example), then it means we can’t dispense your formula until we talk to you, which can take time and slow down your patients getting the medicine they need.

Our Herbal Catalog and Organization

Regardless of what type of herb administration you choose, some factors will be important for all types of formulas:

1. Patient Name
   Make sure to put your patient’s name on every formula. This creates continuity from prescription to prescription and prevents errors and confusions as to which formula belongs to which patient

2. Formula Name
   The system will not let you advance without writing a formula name. Most people name the formula with whatever classic formula their custom creation is based on (i.e. Xiao Yao San, Ding Zhi Wan, etc.) but it can also be helpful to name the formula something that reflects what you are using it for (Insomnia Formula, Stress Relief Formula, etc.) or even a name that has some sort of numerical progression that might correspond to your chart notes so that you can preserve your thinking for each change you might make to a formula (Formulation 1 become Formulation 2 when you add Ban Xia, for example)

3. Dosage and Dosing Information
   Depending on the type of formula you are writing, what you choose for dosing will be different, but make sure that you are telling the pharmacy and your patients how you expect this herb to be dosed (1 bag for 2 days for raw, 3g BID dissolved in hot water before meals for granules, etc..) Making sure that your dosing information is clear is essential to making sure that your patients understand how you want them to take the herbs and how the medicinary should package those herbs for them.

4. Setting refills
   Making sure that you include number of refills and the number of days between those refills is essential to keep your patients happy. They will invariably call looking for a refill of their formula and if you haven’t included that information when you wrote the formula, a long and arduous came of phone tag will ensure while we try to track you down and get that information, creating frustrations for your patients while they wait.

When you are writing a formula, you’ll need to decide if you are going to use a bulk (raw), granule, or patent administration.

If you choose the Bulk (raw) form, you’ll want to pay attention to a few specific items:

1. Work section by section
   Each section on the formula ordering screen contains important information that you should consider with every formula you write for your patients. Please look at each section and the information for that section on the right side of the screen to make sure that you are including all the necessary information for your patients and the pharmacy

2. The price of raw herbs changes by quantity ordered
   As you add herbs and grams into the formula builder, the price per gram and for the total quantity will be displayed. This price is higher for smaller quantities of herbs and lower for greater quantities. As with most things, buying more of a product can bring the price down. We have placed those tiers of prices at levels that reflect the price of each individual herb, its frequency of use, and the common dosages for those herbs such that dosing in the upper range of the standard dose will yield the best price for that herb.

3. Add specific instructions at the end in the “Special Instructions” section
   If you want the medicinary to do something special with your formula, beyond the inputs you entered in other sections like short-boil (i.e. package it all in one bag, grind half of it into a powder and leave the other half whole, tell the patient something specific when they pick up their herbs), this section is place for that information. If you feel like your instructions are confusing or aren’t getting your message across, give us a call and talk to a pharmacy person directly (971) 288-5939

If you choose the granule form. there are some different items to consider:

1. Root & Branch stocks a large collection of pre-blended formulas
   (You can take a look at the list here) These formulas have been cooked together and then made into granules, preserving the original synergy of the formula. While most of us prescribe single herbs, even in granule form, and combine them to create a formula, Root & Branch may not have the single herb you are looking for but we likely have the base formula you are trying to build. You can type the name of that formula into the formula builder as if it were a single herb and if we have it, it will appear. You can then set the quantity of that formula and add singles to it or even combine it with other whole formulas.

2. We can encapsulate granules for patients
   It involves and additional fee and some more time, but we can encapsulate granules for your patients if that makes it easier for them to take their herbs. Our process uses Vegan 00 size capsules with approx 500mg of granule per capsule. Please make sure that your dosing information reflects the number of capsules you expect the patient to take.

Remember, we want to help you do what you do best.

Have an unconventional item you want to try and make? Looking for Sans, Wans, or Gaos?
We can help make that a reality for you.

Give us a call (971) 288-5939 or send us an email info@rootandbranchpdx.com so we can talk about how we can help

Creating Efficiencies: Using your Herbascript™ settings to make cooking bulk herbs easier

Writing herbal prescriptions in the Herbascript™ system gives practitioners a variety of ways to design their formulas by choosing to write scripts by day, by bag, or by total amount needed. Whether you are a granule or bulk dominant prescriber, thinking about how you set up your presceiptions makes it easier for patients to understand how much herb they are taking and in the case of bulk herbs, how to best cook them to get the greatest potency and effect.

For Bulk Prescriptions:

Herbascript™ gives you the option to set up your prescription as “herbs per day” or as “herbs per bag.” This choice mostly reflects how you think about your prescriptions as you write them. For me, I always think about herbs as a “per day” thing. Even for granules, when I design my dosing, I think about how much herb I want a patient to take per day. For bulk formulas, I choose the “total per day” option and then write a formula that might look something like this:

Gui Zhi 12g
Bai Shao 12g
Zhi Gan Cao 9g
Sheng Jiang 6g
Da Zao 6g

Take this amount of herb per day for 5 days.

Herbascript™ will also ask you to set the number of bags you want these herbs divided into and most people default to setting the number of bags as the same number as the total number of days. In the above example, 5 bags for 5 days, one bag per day. Simple enough.

However, one of the big struggles we have with patients cooking herbs at home is the overall compliance with cooking instructions that can feel overly burdensome. Many patients complain about the amount of work it takes to prepare their herbs - doing a double boil of a bag of herbs every day. And in fact, if we are sending them home with one bag of herbs per day for five days, we have told them in so many words to cook herbs everyday.

But in reality, those patients could cook all five days of herbs at once and store the finished decoction in the fridge, reheating them as needed. Cooked herbs are like any other food item with a 5-7 day shelf life in a fridge between 32 and 40 degrees Fahrenheit. So even if you have a bulk prescription that is for 7 days or 10 days, you could set the total number of bags at 2 or 3, and we will bundle up the herbs accordingly, taking some of the burden off of patients to cook their herbs daily.

In order to get that information to us, just do the following steps:

1.) Set your dosage mode for Raw (Bulk) formulas to “per day”
2.) Choose the total number of days for your formula
3.) Pick the number of bags that reflects the number of times you want that patient to cook herbs (5-7 days could be 1 bag, 10 days could be 2 bags, etc…)
4.) Write your formula as usual and Herbascript™ will do the math and tell us (the pharmacy) how to pack up the herbs.

Being intentional about your days to bags ratio will help your patients brew their decoctions more efficiently, help build confidence in their ability to make their own medicine, and help to reduce packaging waste for everyone. 

Bulk Cooking Techniques:

The opinions on how bulk herbs “should” be cooked are as numerous as the best pound cake recipes from everyone’s favorite grandma. While I was in school, I asked every teacher I had about the best way to cook herbs and as many of you might expect, the answer was almost always some version of “it depends...” I experimented with nearly every method I was exposed to: from short cooking with soaking to long stewing with no soaking to crushing and boiling to powdering and steeping. Drawing on my experience as a professional cook, I even tested cooking roots and minerals first then adding sticks and fruits and finishing with leaves and flowers in an effort to layer the flavors and deepen the extraction without damaging more delicate components.  To say the least, the possibilities are endless and the best cooking method will depend on the exact ingredients in any formula. Obviously such specificity can create confusion and headaches for well-meaning patients. 

At Root & Branch we developed a standard double-boil cooking method that is available as a cooking instruction template in the HerbaScript system. We designed this method in an effort to make the cooking process easier for patients while also setting them up for optimal extraction. If you have your own instructions, you can add your own template into your practitioner interface by typing your instructions in the cooking settings section. Sometimes the formatting for those automatic instructions aren’t the most aesthetic, so we can always include a handier looking set of cook instructions with your patient’s herb orders. Just let us know how we can best serve you.

Lastly, if your patients are Portland locals and can pick up their herbs from our Multnomah Village location, we can always decoct those herbs for your patients using all the specialized cooking I developed over these past few years. We want your patients to have the best herb experience they can and to get the best clinical results possible.

Takeaways:

• You can use HerbaScript to dose your herbs per day and tell the pharmacy how you would like them packaged

• Consider having patients cook more than one day’s worth of herbs at a time

• Cooked herbs are good in the fridge for 5-7 days and even as long as 10 days if poured hot into sterilized containers

Granule Herbs: Whole Formula or Singles?

It’s no secret that Travis C. and I are both generally bulk herb people. That is, if my patients are at all willing and able, I want them to take bulk herbs. Especially since we can decoct those herbs for patients in the shop, it takes that final hurdle off the field. But the more deeply we get into practice, the more we see that there are many situations and conditions in which patients can benefit from the ease of a granule administration. Whether its traveling or hiking, busy work schedules or kids with delicate palates, our patients have had need of a simpler way of taking their medicine. Enter the granule.

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Think of whole formula granules as a single item with the same sort of collective mechanism of action as a single herb

Naturally since we are bulk prescribers and have learned most of what we know about herbs from mainland China-trained herbalists, we went immediately to prescribing granules in the same way we would for bulk. That is, we would build a formula from single ingredients, taking into account the general 5:1 concentration rule that is applied to most granules and adjusting the dose to reach a similar kind of formula as we would have had in bulk. And this method generally served us well except when we came up against a single herb that we didn’t carry, either because it is difficult to find in granule or because we just hadn’t had a need for it yet. We’d bring in that herb on the next shipment and continue on with patients getting pretty solid clinical results. Yet there was a little nagging voice in my head saying “But what about the alchemy?!”

As individual bulk herbs cook together in a decoction pot, their constituent parts interact with one another and change the way that other components are extracted. Biochemically we think of this as creating variable pH situations, mineral concentrations, and the effect that these variables have on the extraction of other water soluble components. Chinese Medicine-wise we know that the qi of our ingredients is shaped and adjusted by its neighbors in the cooking pot. Without doubt, the interaction of ingredients when making a decoction is part of the overall effect of a formula, classic or otherwise.

So what about our single granule combos? Patient’s were getting better and that is the metric we primarily use when determining the effectiveness of any sort of herbal administration. And yet, what if we could give them herbs that were whole formulas cooked together and then transformed into granules? As it turns out, we could. We just needed to bring in whole formulas from our granule vendor Evergreen Herbs.

“But wait!” your saying. “What if a patient needs xiao chai hu tang but I want to take out the most of the Huang Qin? I wouldn’t be able to do that if I had to use a whole formula granule!”

You’re right, you wouldn’t be able to make that sort of change. But I have something for you to think about it. Instead of looking at the individual parts of Xiao Chai Hu Tang like huang qin and thinking that you would like to reduce the upper burner heat clearing component because your patient doesn’t have signs for that herb, I challenge you to think about it like this:

Xiao Chai Hu Tang harmonizes the shao yang, soothes the liver, and mildly clears heat from stagnation. Think of those qualities as the primary method of action for XCHT. So you can use the whole formula AS IF it were a single component and not worry too much about any individual ingredient in that formula (exempting obvious concerns like allergies of course)

Let me give you an example:

I have a patient with a sense of pressure in their ears that comes and goes, dry and red eyes, difficulty staying asleep, a slight olive cast to their skin, a pale and swollen tongue with toothmarks, very mild lower leg edema, and hypochondriac tenderness. (You’ll notice I don’t include a pulse here because I don’t use pulse much in my diagnostic process preferring tongues and abdomens. But for those of you that use pulse, the following info works even better I think…)

I diagnosed the patient with shaoyang disharmony (xiao chai hu tang) causing stagnation of phlegm fluids in the upper jiao (ban xia hou po tang), fluid accumulation (wu ling san), and heat from stagnation. Using whole formula granules, I was able to write a formula made of 55% XCHT, 30% BXHPT, and 15% WLS that gave me access to all the treatment principles I was looking for with a much simpler method of writing the formula. And sure, I could have taken XCHT and added some ban xia and hou po, chen pi and zhu ru, and a little zhu ling to activate the bladder qi transformation stagnating the fluids and I might have even gotten the same results. But it was intellectually fun to work from a different angle and to flex my diagnostic and herbal muscles to see how it felt to try something new. It is not to say that one form of prescribing is superior to the other, just that thinking of whole formula granules almost as singles gives us a new way to prescribe granules to patients.

This method of whole formula prescribing is more common in Taiwan than on the mainland but has a very robust clinical record of getting solid results. You can listen to more details about granule creation, concentration, and dosing strategies by listing to this great podcast from Qiological where herbal knows-alot, Legendary Herb Company founder and friend of Root & Branch, Eric Brand talks about the ins and outs of granule herbs.

Takeaways:

• Think about using whole formula granules for their mechanisms of action collectively.

• Combine different formulas almost as if they were singles to achieve certain actions and worry less about their constituent ingredients

• No one method has all the answers but trying new ways of prescribing can keep your diagnostics fresh and effective.