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. More information is better
    In all cases, communication 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

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:

12 herbs.jpg

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.


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.

granule herbs.jpg

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.