How Multidisciplinary Care and Smarter Tools Can Transform MS Management: Steven Kheloussi, PharmD

Managing multiple sclerosis (MS) effectively requires more than finding the right disease-modifying therapy. It demands coordinated teams, intelligent systems, and a health care infrastructure that meets patients where they are.

In this interview with The American Journal of Managed Care^® (AJMC^®), Steven Kheloussi, PharmD, principal consultant at Kheloussi Consulting, discusses the practical realities of delivering evidence-based MS care. From the promise and pitfalls of clinical decision support tools to the role pharmacists can play across care settings, Kheloussi offers his perspective on what it takes to truly individualize treatment.

This interview was lightly edited for clarity.

AJMC: In what ways can clinical decision support tools be integrated into practice to personalize MS treatment more effectively?

Kheloussi: This is a really good starting question, and I think this is complicated. Clinical decision support tools in general can be really helpful, as long as they're not overburdensome for patients, for providers, or for the health systems—and there's always the potential for the clinical decision support tools to lead to information overload or alert fatigue. Those systems have to carefully be integrated and designed to actually serve their purpose, which is to support clinical decision-making, not actually replace that clinical judgment.

I would say that some of the best practices for these tools involve combining multiple data sources to individualize patient care, so rather than requiring clinicians and systems to manually pull all of the information that plays into a treatment decision—which could be relapse history, MRI activity, disability progression, comorbidities, medication, treatment history, how patients have responded to medications in the past, and all of the different things that play into treatment decisions—these clinical decision support tools can pull all of that information together and then prompt providers, or even patients, systems, etc., to react in a way that aligns with best practices. This minimizes the possibility of overlooking those subtle clinical details.

The other thing I would say is, when they're embedded into EHRs [electronic health records], they can really be helpful to identify clinical signals earlier, and then they can also be used to reduce some of the inconsistency among providers. That can help with continuity of care, especially if patients are bouncing between different providers for one reason or another, and then they can also incorporate shared decision-making tools to help incorporate patient goals. I think the importance of incorporating patient goals into treatment can't be overstated. In general, I think there's a lot of value to be gained by using those clinical decision support tools.

AJMC: What are key barriers health systems face in implementing evidence-based MS care?

Kheloussi: Building off the previous question, there's somewhat limited uptake of clinical decision support systems across the board—particularly as it relates to systems and patients, but less so with clinicians. I think there are some data that show that clinician uptake is around 65%, but that means that even about a third of clinicians don't effectively use their clinical decision support tools, which is obviously a problem. And those numbers are even less for patients and systems when they're incorporated for them. The key, then, is that we have to consider the barrier of using these in a way that enhances or supports clinical decision-making and doesn't necessarily replace it, and it needs to be implemented in such a way that it feels natural to use.

I liken this to when you're driving through a school zone and you see a sign saying not to go over 15 miles an hour. It's one thing to put that sign up, but everybody's not going to follow it. You also have to design the roads in such a way that people aren't going to be able to speed through them. Maybe you use a single lane instead of multiple lanes, you use traffic lights, etc. The idea is that the same holds true with these clinical decision support tools—that it's not enough just to implement a process change, but it really needs to guide everybody to use it in a natural way. That's one barrier that we have to think about.

The other that came to mind is that—and coming from somebody who's spent over a decade in managed care pharmacy, it really pains me to say this—prior authorization is also a barrier. You know, as well-intentioned as prior authorization is, it's typically implemented at the population level, which limits the ability for the managed care organization to individualize those restrictions up front. That means that patients, unfortunately, may face some barriers to filling their prescriptions, at least in the short term.

AJMC: What role should multidisciplinary care models—including neurology, pharmacy, rehabilitation, mental health, etc.—play in MS management?

Kheloussi: To me, this is not necessarily a matter of if patients with MS need that multidisciplinary care, but instead, a matter of how we can ensure that they have access to every specialist and every care provider that they need to have access to. It’s not just a neurological disease, and there are data to support that multidisciplinary care improves outcomes in MS. We have disease-modifying therapies that address inflammatory activity, but they don't necessarily address the broader drivers of disability, like widespread physical and cognitive and emotional symptoms that these patients have. And those are the ones that really impact quality of life, so incorporating multidisciplinary specialists to help patients through those different aspects is important. For the physical aspects, we need physical and occupational therapy. Helping patients through the emotional burden of the disease by looping in mental health providers is also going to be really important. And then even social workers helping patients just gain employment can have a meaningful impact on well-being as well.

You mentioned pharmacists, and I want to point that out as well. In some settings, I would say that pharmacists are able to follow patients who are prescribed these disease-modifying therapies to help them with adherence and help ensure that they are being monitored appropriately, in line with the FDA labeling and best practices, addressing any challenges in accessing therapies that they might have. Specialty pharmacies are also going to be involved in the dispensing and can help with prior authorization. They can help with patient assistance programs if the patient needs financial support, and community pharmacists can even play a role by helping with something like smoking cessation, which has been tied to improved outcomes in MS. It's not really optional to incorporate this multidisciplinary care; it's just a matter of how exactly do we get patients all the services that they need?

AJMC: What are some best practices for care coordination between specialists, primary care, and community resources for people with MS?

Kheloussi: You pointed out the community resources, and that's an excellent point that I would highlight here. Patients can see a whole lot of different specialists, providers, social workers, etc., but the lowest-hanging fruit is just connecting them with MS societies or care coordinators or nurse case managers from the payer side who can really help with connecting them to those additional community resources that they need. It all varies depending on where the patient is with their disease and what level of resources they're going to need. Those different, for lack of a better term, resources—the MS societies, the care managers, etc.—can help determine where that patient is in their care and what sort of resources they're going to need to help them. Do they need wheelchair access in their home that they don't have right now? Those sorts of things, maybe a neurologist is not necessarily helping with on a day-to-day basis. That's the lowest-hanging fruit.

Another thing that I've seen in the past is, depending on where these patients are being seen and especially if they live in a rural area, they may have to commute to get to their health system where they have their appointments. Another opportunity would be to coordinate visits among different providers if they are at all able to do that, especially if the providers are within the same practice. Realistically, that's where care managers come in. They can help with things like that, which seem like very simple, straightforward things to do, but they are quite complicated when you consider that there are possibly hundreds or thousands of MS patients—and not just MS patients—that these specialists are seeing all the time. Then primary care providers have their thousands of patients that they need to coordinate schedules with. It becomes very challenging to sort through schedules and whatnot when it comes to coordinating care like that, but that is sort of an ideal situation if we can get that done.