Many hospitals in the U.S. are incorporating integrative clinics that include Traditional Chinese Medicine. Cleveland Clinic has led the charge for adding a traditional Chinese herbal medicine clinic to their existing acupuncture program. This movement has been revolutionary. One reason they stand out is because of their openness about their program. While other notable integrative hospitals remained resistant, and some quiet about existing in-house Chinese herbal medicine practices, The Cleveland Clinic Foundation went all the way in support of both acupuncture and Chinese herbal medicine. This was because of a trailblazing and determined Jamie Starkey, LAc, Program Manager and Lead Acupuncturist at the Tanya I. Edwards MD Center for Integrative Medicine at Cleveland Clinic Wellness Institute helped create a vision for the program and then equipped it with the highest quality practitioners.
Galina Roofener is an Herbalist at Cleveland Clinic in Ohio. She joined the Integrative Medicine Department just before the TCM Herbal Clinic program got off the ground. This Q & A series addresses Galina’s process at Cleveland Clinic, where she began, what helped her get there, and how she plans to keep the Chinese herb program a success at the Cleveland Clinic.
Shellie Rosen: Galina, can you share a bit of the history of the Cleveland Clinic Wellness Institute, and how Chinese herbal medicine became a part of the program?
Galina Roofener: When the Tanya I. Edwards MD Center for Integrative Medicine was opened 11 years ago at Cleveland Clinic Wellness Institute, the Ohio state board licensed acupuncture, but there was no law permitting the practice of Traditional Chinese Herbal Therapy. Jamie Starkey, the Lead Acupuncturist at the Cleveland Clinic, and the visionary behind the concept of the program, always intended for the program to include in her words, "all four pillars of Chinese Medicine." The moment in 2013 that a higher law permitted the practice of Traditional Herbal Medicine, Jamie Starkey and former Medical Director Dr. Tanya I. Edwards guided Cleveland Clinic to promptly begin a traditional Chinese herbal medicine clinic.
SR: Jamie Starkey and Dr. Tanya Edwards faced a number of challenges to get the Chinese herb program into the existing acupuncture program. It was a long process. What were the specific challenges?
GR: The herbal clinic was born from the collaboration of Jamie Starkey and Tanya Edwards MD. The late Dr. Edwards was a great advocate of a Chinese herbal therapy clinic; she and Jamie had worked closely together and developed a working concept of a traditional Chinese herbal medicine clinic. Jamie knew she needed an integrative practitioner of Traditional Chinese Medicine that understood acupuncture and Chinese herbal therapy, as well as Western medical terminology and hospital practices. On top of all of this, it was necessary that the practitioner have passed all the board tests for both acupuncture and Chinese herbal medicine. Since the Ohio law was new, there were few who fit the bill. An additional requirement was to pass the TOEFL exam, which can be challenging, even for English speakers.
SR: Jamie Starkey chose you to be a key practitioner of the Cleveland Clinic Chinese Herbal Medicine Clinic. You were now going to be the first Chinese Medicine Herbalist on staff, how did that feel?
Galina: For me it was about being in the right place at the right time, with the right qualifications. My part was nurturing and growing the program. I knew I was a great fit for the program, and I was also nervous. My biggest concern working in my capacity at Cleveland Clinic has been that I have a great deal of attention on me. This program is very public. I am assuming more responsibility than just one patient. I am shaping the future; I am a part of cultivating the garden of the national healthcare system. When patients get results from my treatments, their physician can see that we are being an effective and safe compliment to their practice, and hopefully, they will keep referring more patients and will share the experience with colleagues. If I screw up, it will have a huge negative impact on the profession as a whole.
SR: Other hospital-based Chinese herbal medicine clinics were operational prior to Cleveland Clinic, what do you think makes this model revolutionary and different?
GR: I am in conversation with other practitioners that work with other hospitals, and few are open about their herbal programs. Even the ones that do exist, they are alongside acupuncture. We separated acupuncture and herbal medicine. There are a few reasons why we do this. One reason is because some colleges in the United States are separating the educational programs between acupuncture and Chinese herbal medicine. We wanted to allow our practitioners in Ohio and other states that were only trained in acupuncture (which are many prior to the new law) to be employed if they were qualified for acupuncture alone. Another thing we found was that not every patient wanted to receive treatments of both acupuncture and Chinese herbal medicine. Additionally, not every patient is appropriate for both types of therapy and we didn’t want that to become confusing for the patient or referring physicians.
On the administrative level there is good reason to keep the programs separate as well. Billing and record keeping in the realm of Electronic Medical Records (EMR) is different for acupuncture than for Chinese herbal medicine. Our major goal is to create a reproducible model of TCM herbal clinic - to be practiced by any hospital system, or private practice, at multiple locations of a hospital system, in different sites. Since different states have different rules, we wanted to create a program that was across the board flexible with compliance. Our model is flexible and adaptable.
SR: Why did Cleveland Clinic choose to outsource Chinese herbal medicines? In the beginning of the program, patent formulas were in-house, what were there difficulties with that model?
GR: Creating a model that was reproducible with no financial investment was thought to be more appealing to large hospital systems or small start-up private practices. We figured this made for an easy answer to a highly reliable model that can go anywhere. We want to be present at every hospital in every location. The only solution to achieve this goal was to utilize an established model of conventional medicine practice and outsource compounding to a specialized herbal pharmacy.
An inventory is a huge expense and complication. To compound and dispense a formula myself is time consuming and, therefore, financially not feasible on one hand. On the other hand, hiring staff that are not trained in traditional herbal medical prescriptionology to run a Chinese herbal medicine compounding pharmacy, leads to a higher incidence of clinical error and mistakes. In addition, we would become subject to FDA herbal compounding pharmacy regulations that is more than a hospital would like to deal with and we would be limited to patent formula only and that was not an option for our vision.
SR: How do you decide what product line and pharmacy to use?
GR: We wanted the highest quality product and great consistency of a preparation. The ease of online prescription submission, the reliability of compounding practices, the labeling according to FDA laws, and the excellent customer service for our patients (which reduces any line of error on our part), is why we chose Crane Herb Pharmacy.
Chinese herbal medicine is a presecription medicine and should be treated as such. We aren’t just selling formulas to sell formulas; we are prescribing custom formulas for specific patterns for specific patients. One of the reasons why in Western medicine we have separated the doctor and the pharmacist is because of this very issue. In some states, doctors can’t sell supplements out of their office, because of "necessity of use." We are practicing better ethics by forcing the hand of a prescription for every formula. Plus, the use of a pharmacy meets patient’s high standards and expectations, therefore enhancing our credibility in the eyes of the MDs. We do not practice the style of Chinese herbal medicine in plastic bags of "witches brew" with pinyin scribble, which is absolutely unacceptable. We do better.
SR: What is record management like in the conventional medical system?
GR: The most important part of a hospital practice is Electronic Medical Records (EMR). Most traditional Chinese medical schools in the U.S., to the best of my knowledge, do not teach any EMR recording according to conventional medicine standards. It is a big stopping point for our employment in a hospital. At the Cleveland Clinic, we use "EPIC," the "Rolls-Royce" of EMR. Now try to imagine trying to park it in Times Square in rush hour traffic. Got the picture? It is about the same way you might feel trying to use a conventional EMR system for the first time to record a Chinese herb formula prescription, but with time, it becomes a great skill. Practicing in a hospital increases the risk of being a subject to a malpractice claim as a practitioner and you will be the defendant on the basis of your records!
SR: This is necessary information for anyone, not just hospital-based practitioners, how do practitioners learn more about the Cleveland Clinic model?
GR: I speak about these and other EMR topics in my class "TCM Herbal Practice Safety Standards and Medical Errors Prevention Guidelines: The Cleveland Clinic Model" extensively. More info can be found at www.AsianTherapies.org/Academy.
SR: Thank you for sharing the Cleveland Clinic story. I imagine there are readers that find themselves nervous about major health care systems getting involved with Chinese Medicine, as well as readers that think "it’s about time" this shift has occurred. Many thriving practices throughout the U.S. have not yet felt the need to integrate into mainstream medicine. That said, pending ICD-11 codes are changing the way we discuss our medicine, and with or without a national consensus on the matter, Chinese medicine is being standardized for a variety of reasons. I would love to keep this conversation open and talk with you about how your work at Cleveland Clinic in the Chinese Herbal Medicine Clinic, is affected by this changing terminology and medical language.
GR: Thank you! I would love to share more about herb-drug interactions, herbal side effect reporting, Doctor – TCM Practitioner and TCM Practitioner-Patient communication, logistics of a hospital-based TCM herbal clinic and ICD-11 next time, and also more about this growing and constantly improving process at Cleveland Clinic. I wish to see more and more confident, professional and successful practitioners that know how to value this medicine alongside Western medicine.
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