IJMSC Author Spotlight: Nina Bozinov, MD, MS

Author Nina Bozinov, MD, MS, was the first author of Integrating Clinical Pharmacy Services Into Comprehensive Multiple Sclerosis Care Teams: A Narrative Review of 4 Models published in the International Journal of Multiple Sclerosis Care (IJMSC) in April 2025.

Nina Bozinov, MD, MS.

[Image courtesy of the author.]

Bozinov is the director of the Kootenai Clinic Center for Comprehensive MS Care in Coeur d’Alene, Idaho, serving patients across North Idaho, Eastern Washington, and Western Montana. She is also a clinical assistant professor at the University of Washington School of Medicine.

She recently sat down with IJMSC to talk about the paper, her career path, and her research.

International Journal of Multiple Sclerosis Care (IJMSC): Tell us the story of your paper “Integrating Clinical Pharmacy Services into Comprehensive MS Care Teams: A Narrative Review of 4 Models.” Where did the idea come from, and how did you form the team of researchers?

Nina Bozinov, MD, MS: It was actually pretty interesting. We used to have these…meetings that were multidisciplinary, as part of the National MS [Multiple Sclerosis] Society Health Care Council, and one of them was about pharmacy models in the clinic. Usually, the meetings [were about an hour long] and at the end of the hour, we all just wanted to keep talking about it. We were excited to discuss the challenges we found in advocating for having a pharmacy team or pharmacists within the clinic, how the models can look so different…. We wanted to show how different clinics that were all considered comprehensive MS care centers can have different ways [of integrating] pharmacy. One of the things we heard from the people who were not utilizing pharmacy is that they didn’t really understand all the roles that pharmacy could play within a clinic…. This seemed like a good opportunity for everybody to share how they were utilizing pharmacy and whether that was directly within the clinic or off-site, or as official visits that pharmacists were able to bill for or not bill for. We realized that with the unique nuances of these different clinic models, it was a great way to highlight how [integrating pharmacy] can look different.

IJMSC: What about this research was surprising or interesting to you?

NB: I would say, it is the structure of the different ways a pharmacy team can be set up. Whether or not the clinic, like my clinic, has a number of specialty pharmacists and then, perhaps, a single pharmacy technician, vs another clinic where they have maybe 1 specialty pharmacist and many pharmacy technicians. And thinking a little bit about the different ways that we can show our value, whether that’s through prescriptions, through specialty pharmacy, or whether it’s through direct billing for a clinic visit. Within each different organization, that process could look different, and certainly, as we think about even things like different state laws.

IJMSC: What is one thing you would like IJMSC readers to take away from your article?

NB: Every time a pharmacy team is integrated into a system, it can look different based on your needs and your setup. [There’s] not one prescribed pathway [for] having a pharmacist or a pharmacy team integrated into comprehensive MS care. It has to work for the type of environment and patients and the organization that you are functioning in. There has to be flexibility…and that’s why we highlighted 4 different ways that we had it set up. However, it may look totally different for you, and you may be able to take different pieces from each of those models and figure out what works for your team, your organization, and your patients.

IJMSC: You’d like the clinical impact to be an empowering story of how to make a multidisciplinary team that includes pharmacy?

NB: Yes. I think that what I’ve seen throughout the last 5 years of working with pharmacy [is] what a critical role that they can play in patient access to disease-modifying therapies and other symptomatic medications, safety, polypharmacy, monitoring treatments, and safety monitoring. Sometimes I see that pharmacy is so separated that it ends up being more of [sending a prescription] off to a prior authorization team that you never interface with. I think it’s really important to try to take it to the next level and integrate them in some capacity into the MS care team.

IJMSC: Are there next steps for this line of research? Are there things that you think could or should be studied further?

NB: One of the biggest things that we struggled with in this paper is understanding what outcomes we could measure. Sometimes that can be tricky because of our different systems…we’re not all on the same electronic medical record system. We may have different ways of tracking things, like time to fill, time to infuse. How do we objectively show the value the pharmacy team can bring? Certainly, for a pharmacy team that is billing direct patient visits, you can show some revenue generation from that, but I think the other tricky part is, how do you show all those other things, like reduced hospitalizations because you’re more cautious with medication interactions, or capturing near misses as we think about things from a safety standpoint? Or comparing something like not having to go through step therapy, if we think it’s inappropriate for a certain patient for a disease-modifying therapy, getting earlier access to better treatment, as we know that for many people, access to high-efficacy treatments at the beginning leads to better outcomes overall. But how do you show that in a real-time clinic setting? I think if we came up with some metric to track some of these outcomes that would be important….

IJMSC: Throughout our conversation, you’ve talked about multidisciplinary care and how it’s integral, and you’ve even spoken about some challenges. Are there pros and cons that you see? What are the challenges to fully implementing multidisciplinary care in the MS clinic?

NB: I think [from the perspective of] an integration of pharmacy services, the challenges [could] include many things, simple things like space. If your clinic doesn’t have the space to have pharmacists within the clinic, they may be off-site. And so sometimes those conversations that just happen about patient care can be different when they’re talking face-to-face about the nuances vs a staff message through an electronic medical record system, or vs some other kind of messaging. If you can’t have them embedded within the clinic physically, you may miss out on some of those opportunities for them to understand the complexity of a patient situation as you’re thinking about a treatment option. Another thing that can be tricky, depending on the model, is that sometimes it is helpful to have formal clinic visits because then you have the pharmacist doing documentation in your electronic medical record system, rather than in the background where it may not be captured in the same way. I think there are a lot of nuances to different structures within that patient interaction, whether that’s more formalized as a clinic visit or a pharmacy-initiated clinic visit or something that’s more in the background.

IJMSC: Did you take anything from the other models in the paper?

NB: I’m most jealous of the ability of the pharmacist to [have] face-to-face interaction with the patient, almost set up like a visit. In my model, it’s sometimes in real time. I’ll be with a patient, we’ll have a question about treatment access…or something, and thankfully, because my pharmacists are within the clinic, they can pop into my exam room with me and help address those questions. I love that aspect of our model. I think the part that I wish I had available was the ability for that pharmacist to set up and independently have more of a structured clinic visit with a patient, like some of the other models have.

IJMSC: How did you choose to specialize in neurology and then find your way to MS care?

NB: I did something called the University of Washington WWAMI [Washington, Wyoming, Alaska, Montana, Idaho] program. I spent the first year of that program in Bozeman, Montana, and then moved to Seattle, Washington, for the next 3 years. I was paired with a mentor, and my mentor happened to be a neurologist, and so I got some early exposure to neurologic care, especially as we would go and see patients in the hospital setting…. I think that was really important, because oftentimes in those rotations, neurology ends up being something you’re not exposed to early on, and [that can] lead to fewer people going into neurology. Out of my graduating class, I think I was the only one out of more than 200 people who chose to go into neurology for residency. We definitely need more neurologists in general. Then I went to Stanford [University] for intern year and my neurology residency. As part of that, I connected with another great MS specialist, Jeffrey Dunn, [MD,] who’s the division chair, and so got to spend time in clinic within that first year of the residency. I got to see the deep connection that you can form with a person with MS, and I think that really got me interested in that comprehensive model of MS care and the treatments, whether that’s disease-modifying therapy, symptomatic management, lifestyle management, all of those aspects. I really became interested in MS early on in my residency program, and then I ended up staying at Stanford for a 2-year fellowship. I had a Sylvia Lawry Physician Fellowship through the National MS Society, so I did a 2-year fellowship, and also did a master’s degree in epidemiology and clinical research that allowed me to get a deeper understanding of patient-related outcome measures, which is what I did my master’s thesis on using the iConquerMS database as part of the Accelerated Cure Project. That helped me shape how I think about patient care and research, and these outcomes that are really important for the quality of life for a person with MS. Rather than only focusing on 1 piece, [I was] focusing on that more global view. After that, I decided to come here to Coeur d’Alene, Idaho. They were looking for an MS specialist to fill the gap after the one prior had left, and it ended up just being a perfect alignment of vision because they wanted a comprehensive MS care center.

One of the hopes and goals of the WWAMI program is that people end up practicing in one of the states or regions where we that the population can be underserved. Much of the focus is on those primary care specialties, pediatrics, internal medicine, and family medicine, although we certainly know there are a lot of neurology deserts out there as well. I was the only fellowship-trained MS provider in the state until recently. There is now another one in Boise, so she’s at the bottom of the state, and I’m at the top of the state.

IJMSC: Is it difficult to offer care to that many people? What are the challenges and opportunities out west for an area where, like you said, there are many neurology deserts without providers?

NB: I’m very lucky that I have a great team. In addition to a dedicated medical assistant, I have 2 nurses who started with me 5 years ago, and [they now] have the international certification for MS care for nursing. They help a lot because treating people with MS who live in different states or live many hours away from you creates a lot of challenges, as we think about just logistics of care. Can people even get to you in the winter months? But also, not everybody can just come here for physical therapy or speech therapy or all these other discipline services. We have to think [beyond] our local referral network. How do you refer out to these other locations when [the patient has] to go some place closer to home? There’s a lot of care coordination that happens when people aren’t in your direct vicinity. And then I have an advanced practice provider who has been with me for 2 and a half years, and he helps us so we can continue to take new [patients with MS]. We basically have a shared model, so we alternate clinic visits. Instead of at some point me saying, “OK, I’m capped, I’m not able to take any more [patients],” we came up with different ways so that we could continue to have [patients with MS] get established here.

We’re also lucky that we have a physiatrist, Glen House, [MD,] a physical medicine and rehab specialist who joined our clinic over 2 years ago. It’s incredibly helpful when patients have more complex spasticity, neurogenic bowel, bladder, or ambulation issues to have that shared patient model of them following with both of us, because he has a completely different skill set than I do.

The other thing I didn’t want to do is a model where you’re only seeing patients who are on a disease-modifying therapy or have active [disease], and otherwise, primary care is following up. I think some of the approach to MS can be unique to having that MS mindset. And I do feel like even if [the patient is not on] an MS therapy, or even if people are not on medication management, there’s so much that we can do from an education perspective that I do think it can be beneficial for people to still follow an MS clinic.

IJMSC: It highlights the importance of multidisciplinary care. Do you have a current research project? Are you working on something in clinic?

NB: There’s always something to be working on in clinic! From a research standpoint, we are participating in the Multiple Sclerosis Implementation Network (MSIN) through the MSAA [Multiple Sclerosis Association of America]. It’s a patient registry. We’re one of the sites for that. And I am always looking for opportunities to participate in other kinds of research. I certainly think one of the challenges, unlike at a big MS center, is [for] things like [Expanded Disability Status Scale] raters, it’s me and my [advanced practice provider]. We don’t have multiple people to do it. Sometimes trials require a bigger staff. We do have 2 clinical research coordinators, so they help us collaborate when we participate in research studies. The other big thing I’ve been working on is we have patients fill out a lot of patient-reported outcome measures, such as the timed 20-foot walk, the Modified Fatigue Impact Scale. [We’re] trying to capture this patient experience [more] than just based on MRIs and exams. We are still working to get that implemented within our electronic medical record system, so that even if it’s a virtual patient, we could still have that information to help guide care, and so patients don’t have to necessarily come in and fill it out during their clinic visit.

IJMSC: That’s the advantage, I guess, of our expanding digital footprint.

NB: For sure. As we think about broadening our view and not just thinking about relapses, but about clinical symptoms changing over time and how to capture things like MS progression, I think we have to take all of those different pieces that are available to us [and] try to put them together, to…bring us more information. I just had a patient the other day, and she was telling me, “Well, after I did this treatment, my walking improved, but my cognition worsened,” and we were able to look back from [today] to 2021 and see how much faster her timed walk test had become, and that some of her cognitive testing had worsened over time. Having that data to track longitudinally to help support what the patient may be telling you can be really helpful.

IJMSC: How do you see clinical care and research meeting? How do they influence each other, and how do they interact?

NB: That’s a pretty big question. I think it depends on how we think about clinical care and research. I think we can think about many of those traditional models, like enrolling in clinical trials and bringing patients access to potentially newer medications that are not yet available, [and] clinical care and research can integrate that way. We can think about some of these things like the registry or understanding the patient experience, and how [they can allow] the patient to track their symptoms over time, as well as inform the clinician. I think it’s important for us to think about research integrating into clinical care because I do think it brings something to our patient experience. Circling back to that access piece, if we only have these research-related things happening at academic centers, we’re missing a big portion of people [who may have] MS. That’s why some of us are also trying to work to bring those things into our clinical practice.

IJMSC: Do you have any opinion about the growing use of artificial intelligence [AI] in research, in the clinic, in any of the various ways that seem to be proliferating right now?

NB: I think that utilizing AI as an ancillary tool can be incredibly beneficial. I use AI [when] I’m trying to look certain things up and provide additional information, or honestly, even coming up with things like comparison charts or tables. It can be so much faster to implement those things then putting it all together ourselves, step by step, going through the nitty-gritty. Of course, like anything that we’re reviewing, we have to be mindful of making sure that that is in alignment with what we know. That’s always going to be the case. I think the key in the clinical space, or even the research space, is some of that transparency. If we’re using those things, we need to say, “Hey, here’s where I’ve used it….” I would say I’m optimistic about some of the uses because I think [AI] can help us see things, maybe like big data, that we just can’t always fully grasp. Of course, we need to continue to use our clinical acumen and judgment to make sure that we’re not misled, and just like we can have things like implicit bias, we know that artificial intelligence can also have things like implicit bias, so we just need to be very mindful as we use it.

IJMSC: Any final thoughts?

NB: We need to continue to advocate for these models that seem to enhance and improve MS care. I would say they’re sometimes not the obvious models that bring in revenue, so there is sometimes a little bit of a discrepancy between knowing how to give the best MS care and helping our organizations understand why that’s important. As clinicians and other team members continue to advocate for why this is important for the person with MS and the MS care model, hopefully, we can continue to get this implemented in more MS clinics.