Making Healthcare Data Meaningful for Learners, Patients and Providers: Josh Schoeller - President of Global Clinical Solutions at Elsevier and CEO of Healthcare for LexisNexis Risk Solutions

Shiv Gaglani: Hi, I'm Shiv Gaglani and today on Raise the Line I'm really happy to welcome Josh Schoeller, one of my new colleagues now that Osmosis has joined the Elsevier family. Josh is president of Global Clinical Solutions at Elsevier and Chief Executive Officer at the healthcare business of LexisNexis Risk Solutions. He has worked in all segments of the healthcare industry in the U.S. over the past twenty-five years specializing in data management and integration, application architecture, predictive analytics and decision support. His role at Elsevier involves ensuring the development and growth of strategy as well as customer satisfaction.

It's a pleasure to have gotten to know Josh over the last two months. I directly worked with Elizabeth Munn, one of his peers who runs the Global Medical Education business who we had on the podcast as well as Jan Herzhoff who runs Elsevier Health Markets.

Two weeks ago, I saw Josh make a major announcement about a Truveta partnership at the One Health Conference, which I talked about a bit on LinkedIn if you follow me there. So, Josh, thanks so much for taking the time to be with us today.

Josh Schoeller: My pleasure, I'm excited to be here. 

Shiv: So obviously, I know a lot about you but for our audience who isn't as familiar with you and your background, can you tell us a bit more about how you got interested in data as a field and then applying that to healthcare?

Josh: That goes back a long, long time. I wanted to work from a very early age. I started lawn mowing and snow shoveling businesses when I was eight or nine years old with my brother. I quickly got into the first job I could get which was McDonald's. I then went on to work at a nursing home but I was looking for something that also worked the brain. I ended up getting a job at a company called Dynamark, which was a data management company. They hired me in as a clerk in the computer room teaching me data operations and computer operations. It happened to be the data center of the old Control Data building where Seymour Cray invented the very first supercomputer. We crushed a lot of data. 

In the very beginning, I was on the banking side of it. I was the customer down in the computer room, loading round reels for the guys upstairs that were coding. They would come down and talk to me about prioritizing their jobs and I would do that in exchange for them teaching me how to code. I got into data science when I was probably a junior in high school even before college and studies began. So, I have been in data and analytics for a really long time. 

Shiv: That's awesome! So, obviously now with Elsevier you play a big role. There's so much data that you guys can handle and are working to de-identify. Can you tell us a bit about how that has translated into a career in healthcare...what your professional trajectory looked like there?

Josh: So, Dynamark was bought by FICO. I spent 15 years there. I did almost everything you can do -- programmer, product development, business development and ran the data management practice. After 15 years, I started a company called Enclarity, which was a provider data management company. We utilized big data technologies to manage every single health care provider in the U.S., every single organization, keep them linked together and keep them correct, current and comprehensive. We then offered that as an API out to various compliance and quality solutions out there on the market. That company was acquired by RELX, our parent company, in 2013. So, that's how I got here. 

But that's what kind of got me into healthcare...moving from consumer data management to provider data management and then I really just fell in love with being a part of healthcare. We're always looking to have a broader mission when we're working as hard as we work. In healthcare, there's so much work to be done. It's very easy to have a noble mission. On the LexisNexis side, we have a mission to create healthier communities and on the Elsevier side, it's to improve every patient outcome. So they're very much aligned and you can imagine they are both mission-driven organizations built around people that are very committed to using data and analytics and content to help improve healthcare in the U.S. and throughout the world. 

Shiv: Definitely! One of the first things I learned when we joined RELX as well was how many clients you have in the healthcare system space. I think globally there's over 9,000 health systems that work with Elsevier, RELX, LexisNexis, and then in the U.S., 97 of the top 100 healthcare systems work with you all. Obviously, there's a lot of great customers and applications, but for our audience -- which primarily are students and faculty at health professional schools -- can you tell us a little bit about some specific applications? How is data analytics actually used in healthcare? What are some of the products or solutions that you all offer?

Josh: We have a really robust product set, and that's probably the reason why our reach is as big as it is. Most people know Elsevier from our 140-year-old history as a publisher. So part of my portfolio is still books for education. Part of the way that we progress the company forward is taking a look at how we can take those books -- which are about 'how do I educate myself' - and turn it into digital content -- which is about 'how can I answer a question at the point of care or when I'm doing research'? And that's really our flagship product-- ClinicalKey with digitized content and search capabilities for clinicians. But we have CK Student for students and CK Nursing for the nursing students, so we've kind of rounded that out. 

We also have PatientPass, which is different patient engagement solutions. We have a full nursing portfolio on nursing education. We have a lot of different offerings that we put together all around our great content. The next evolution is how do we take that content to provide more advanced clinical decision support where we're pairing that evidence-based content with deeper organization of clinical data from the EHR, as well as overlaid data and analytics, to help clinicians make better decisions. 

Shiv: It's all really exciting stuff. In one of our first meetings I talked about one of our great partners, New York University, which is the number two med school in the U.S. and obviously a major health system. The work we're doing with them at Osmosis involves them sending us data on what types of diagnoses their students are seeing in the clinic through their EHR on a daily basis, and then we're sending them back targeted Osmosis videos and content that will help their students better understand those diagnoses for treatment. This is something you guys have talked about and thought about for a while as well. So, we're very excited about that and being able to apply our content in more predictive ways. 

One thing I learned about two weeks ago at the One Health Conference is Jan Herzhoff had you come up and talk about the Truveta partnership. Not many in our audience probably know what Truveta is, so maybe you can give us a bit of background on that. Today, when you presented to the Osmosis team, I was excited to hear how you reached out via LinkedIn to the Truveta CEO and then that led to this great partnership and deal. So, can you just give our audience a bit of a background on that? 

Josh: Yeah, absolutely. It was probably about a year ago. I was on LinkedIn and I saw this press release titled 'Saving Lives with Data' which caught my eye. So I started reading through it. It mentioned Terry Myerson, who came from Microsoft and had founded this startup and got funding and had already gotten fourteen large health systems across the U.S. to sign up with him and to let him leverage their full clinical data for a research platform. 

I thought, "Boy, that's a big undertaking." A lot of people have tried to organize that much data. We're talking about nearly 100 million people and a full longitudinal clinical data set. So, I thought "We probably have some tools that can help them out." I got on LinkedIn, I found Terry and sent him a note and said, "Hey, our missions align. I would really like to see if there's any way we could help you out. We can help you get to market quicker." He called me back and said, "Yeah, let's talk." 

Two weeks later, we had a meeting and went through capabilities. Nine months later, we executed an agreement for us to be the exclusive provider of his de-identification capability or what we call Patient Centric Token. But incrementally to that, he's got very deep clinical data. What we have on the LexisNexis Health Care side is we have one of the largest de-identified medical claims data sets available in the US. Over 2.2 billion medical claims annually, and those are coming in every single day as they're being transmitted from providers' offices to payers, and from payers back to providers' offices. 

If you think about it, he's got a full view into a hospital system, but we have a directional view of the whole U.S. so you can start modeling and doing benchmarks and those types of things with that data. We're also overlaying mortality data -- de-identified again, of course -- as well as our social determinants of health. So we have attributes that help round out conditions that impact your health outside of your clinical condition. You can look at different risk factors and one of the areas in which we're using that right away is looking at health inequities, and how do we start solving for health inequities in the U.S.

Shiv: That's awesome. One of the big focuses of the Raise the Line podcast is this transition to SDOH -- Social Determinants of Health -- and value-based medicine. We've had people on like Dr. Christopher Chen who runs ChenMed, Dr. Rushika Fernandopulle at Iora Health and then Dr. Vivian Lee, who was president of the University of Utah Health System and who also wrote the book, The Long Fix which has become pretty popular. It is perfectly timed too, because one the forcing functions of the pandemic -- apart from the growth of telehealth and consumer-driven healthcare, which we'll get into -- has been this massive surge towards value-based healthcare. So with this data lens on the U.S. healthcare system, how do you view what you do at Clinical Solutions and LexisNexis as being part of value-based medicine, or pushing towards that? Is it just better measurements or how should we think about that?

Josh: Let's just start with, the current spend in healthcare is unsustainable long-term. We have a problem in front of us and the government and private sector spend a lot of time thinking about how we can make the jump from fee-for-service to value-based care. I would say that that jump has been slow because it's hard to change a massive system where the incentives, the reimbursement and the measurements are all in place. 

The main challenge, though, has not been necessarily the financial system updates or the contract updates. The challenge has been in understanding the risk. If you're taking care of somebody with diabetes who's very wealthy and eats healthy food and has transportation to their doctor's appointments and can pay for their prescriptions, their risk factor to you as a provider is much different than if you're taking care of someone who's got that same diabetes diagnosis, but doesn't have access to healthy food, they don't have access to transportation to get to their appointments and they can't afford their medicine. This is a social determinants of health example, but there's many examples of that. 

I think getting the data and driving the right analytics to help both sides understand that has been a big challenge. We're seeing it more and more in pockets. Certainly, the creation of the ACOs -- where the providers and the payers are more of one group where they're working together, I think is a great way to get started. But if we really want it to work at scale, we have to have better data and analytics to drive that risk understanding as well as the outcomes analysis. 

Shiv: Definitely. That's a really good breakdown, and a very specific and good example of an SDOH. Ultimately, it does come down to risk and being able to predict from collecting the data to combining them in really interesting and generative ways, then using it for prediction so that the health systems and individual providers can make the right decisions. 

One of my favorite interviews was with our institutional partner, Kaiser Permanente, which is I think one of the best examples of a health system that was able to combine both the provider and payer side of things. They now have a med school, and their dean Dr. Mark Schuster was on this show. They've integrated a lot of SDOH and value-based medicine into their curriculum already. So, it's exciting to see what the next generation will do there. 

Another big trend that's related -- and kind of going back to your days working in consumer analytics -- is the growth in consumer-driven healthcare. Digital health companies like 23andMe and lots of consumer-type companies like Walmart and CVS are really going into healthcare. What do you make of this trend? Is that overall positive? Does it open up doors to collecting a lot of data? How are you thinking about it?

Josh: I think overall it is positive because it requires engagement in your health. A long time ago I had this idea, because I came from FICO, that just like we have credit scores, we would have health scores and people would actually understand what were the levers to make themselves healthier. And it's not that we don't understand -- you've got to exercise and eat a good diet and go to the doctor, those types of things -- but the reality of it is that culturally, it's still not in front of us. 

However, the move to consumer-driven healthcare means that you're not just going to go to the doctor that's closest to your house or the office that your parents went to. You're starting to do research and starting to make decisions based on cost, quality, preferences. "I look like this, I want a doctor that looks like me," those types of things. I think that's the start of it. 

Certainly, the pandemic heightened the move to digital health or telehealth, which is the access piece of consumer-driven health. You also have the legislative side. The 21st Century Cures Act -- the most significant health legislation in over two decades -- says you as a consumer own all your health information and you get to decide via consent who gets it and who doesn't get it. And by the way, if you want it, any institution that has that, has to give it to you. 

So, we have the standard and FHIR that's out there and we have the legislation. Now, we have to start to get our culture to be able to adopt that. But I think it's going to be very powerful in the future. Think of someone being able to walk into the doctor's office, and instead of showing an insurance card, showing an ID, paying with a credit card, sitting down with the clipboard and filling out 3 pages of paper, they come in with their phone and scan a barcode. The things that we can solve from a patient safety perspective, with not getting records wrongly matched; the things that we can solve from a cost perspective...why are you running that lab again when it was just done 2 months ago? I think there's a bunch of benefits if we can get there, but interoperability is not an easy thing to solve for. 

We see ourselves as potentially sitting right at the heart of that in helping with data standardization, data linking, and authentication of individual identities to make sure you are who you say you are when you're getting your data. We have a lot of solutions that help in that broader utility that needs to be brought into healthcare. 

Shiv: That's really exciting. One of our regular listeners to the Raise the Line podcast, who was also on the podcast as a guest, is Peter Frishauf. I call him the "Godfather of Osmosis" and he's one of my mentors and friends. He started Medscape. He was the first one who introduced me to the FHIR standard of interoperability. I know he's going to be very happy hearing you talk about that in the context of Elsevier and LexisNexis. 

Another question our audience would be interested in that you wear two hats -- Elsevier Clinical Solutions leader and also your LexisNexis role -- how do those two overlap and has that led to actual product integrations? How does the combination help customers?

Josh: I think that's a big part of my charter, and I'm five months in, so I might need a little bit more time. But absolutely, there is a strong hypothesis that as we take our digital content and as we move from being referential evidence-based content into categorizing that and overlaying it with analytics to get it more at the point of care for clinical decision support, that data and analytics are going to be a bigger and bigger piece of that. 

We have a few pilots this year. One working with social determinants of health; one working with our identity data; one working with our de-identified medical claims data where we're starting to utilize that to drive greater insights on how our content can be linked and how that content can be surfaced. I think later this year we will have good progress on some of the next steps that we want to take in better integrating data. Certainly, our clinical path, which is our oncology platform for pathways, that's utilizing clinical data and utilizing our analytics and data capabilities to help define those Pathways as well as linking that with some external data sources. I would say that we're not quite there in market yet, but we have all the data assets at our fingertips, which I don't think any other company can say. So now it's just about putting them to work.

Shiv: That's also exciting. I keep forgetting that you are pretty new to these roles. I’m excited to see where we'll both be if we have this conversation a year from now. 

We launched this podcast when the COVID pandemic began. Everyone was saying 'flatten the curve' which is about health literacy, getting people to physically distance, wear masks and get vaccinated. The other half is 'raising the line' and strengthening our healthcare system, which we at Osmosis look at as training the next generation of healthcare professionals because we've already had massive shortages worldwide before COVID. Now with COVID, it's even worse. 

So, what are your recommendations, having worked in healthcare for some time, around other things we could be doing to raise the line and strengthen our health care system? 

Josh: What you just outlined around staffing is probably the most critical. We need more doctors, nurses and frontline healthcare workers in general to be ready for this. What we learned during this is we have real capacity concerns. If I went to the next level of concern, it's basic equipment that wasn't available during this. I would also say that the pandemic really heightened the obvious truth that there are true health inequities and access issues in our health care system. Those are probably more public health-focused going forward. 

But one of the interesting things is, if you start looking at other global systems in healthcare, the U.S. considers healthcare to be very clinical only, where I think in a lot of other nations public health and healthcare are very closely linked. I hope that out of this pandemic, we start to look at how we can link those a little bit closer. And again, social determinants is a big piece of that. You can have the analytics to understand what people's deficiencies are or their access issues are, but if you don't have the investments in your local community public health -- whether it's a food bank or Meals on Wheels or transportation to get to doctor's appointments and all those things...most of those are largely underfunded.

Hopefully, there's an awareness around improving focus on all of those so that next time this happens -- if it ever does, and we all hope it doesn't -- we are better prepared. We know going into it not only how we have to act and behave as a society, but also that the people on the front line are better supported. 

Shiv: Totally. Actually, that's a good transition to the next question, which is if you were to help redesign curricula for medical or nursing schools -- as Osmosis is doing in partnership with many of these schools to fill in knowledge gaps -- what are some of the topics you'd be interested in making sure that the next generation of healthcare professionals actually knows about?

Josh: I'll give you my data geek answer, which is I think more and more data and analytics are going to come in contact with clinicians in their daily practice. In some ways, that's certain to be seen as a threat. I think we need to re-level set and do some training. Now certainly these tools, data and analytics need to advance so that they're actually helpful in all cases. All clinicians have to do more and more each day with less and less time to do it. If we look at these data and analytics as driving additional insights to help them do their job better, to make them more efficient, I think some more training around that piece would be helpful. 

On the other side of it, I helped George Washington University to define a curriculum for their Masters in Public Health, and a lot of the things that we talked about on the public health side would be helpful to have a little bit deeper dive in as far as access to resources and again that non-clinical understanding of a person's holistic health. 

Shiv: I love the idea you just mentioned of the FICO score, but for health, and we have a long way to get there but the rise of digital health companies has certainly helped push us that way. One of my favorite guests on the podcast was Anne Wojcicki who runs 23andMe. We've worked with them on a whole course for patients and providers on direct-to-consumer genetics. When they were coming out, one of the biggest complaints from physicians and others about any direct-to-consumer healthcare was that this led to cyberchondria...people getting these genetic analyses and not knowing what to do with it or thinking that they were definitely getting cancer because of one genetic variant or something. 

A lot of it comes down, as you said, to engagement and education. I think if anything, it's good that consumers are taking more of an interest -- and we can incentivize them to take more of an interest in this -- but then it's ultimately important for healthcare professionals to accept that data and for us to help them by developing technologies so that they can better interpret that data and leverage it as opposed to it just being noise. 

Josh: Absolutely. You saw last week in the One Health launch that the first pillar of change is "battling the infodemic". More data doesn't necessarily mean more knowledge, and I think we're in a unique position to help ensure that this is evidence-based and it's peer-reviewed and it's not an op-ed. We have to really have the highest bar set for the curation of information. That's really core to our mission at Elsevier and certainly within Clinical Solutions. 

Shiv: Totally. One of the reasons we decided to join up with Elsevier is its 140 years worth of providing trusted healthcare information to professionals, scientists, and the masses. 

So, speaking of providing information to young professionals, since the Osmosis audience primarily consists of millions of current and future healthcare professionals, is there any advice that you would give to them about meeting the challenges of COVID and approaching their career in healthcare, maybe analytics or just careers in general?

Josh: Buckle up! It's a super exciting, super rewarding, super challenging field. You don't only have to be wicked smart to be a good clinician, but you also have to have the empathy and the compassion to work with people every day. On the other side of it, it's super rewarding. We're going through a healthcare renaissance. That's been my new term lately and it's a lot of the topics that we talked about today. Whether it's the move to consumer-driven health, digital health and telehealth; the move to value-based care; the new regulations around data access; the pandemic that we're in and trying to get out of -- all of these things are changing healthcare more rapidly than it's ever changed before. 

So, if you have the ability and the want to go in and be a health care clinician, you're the heroes of the future because we need it more than ever. The baby boomers are getting older and it seems like there could be additional ongoing risk of other pandemics and new things coming onto the scene. Being a part of that and being in front of it, I think is more critical than ever. I think the non-clinician community needs to be thinking about how we do a better job of preparing and protecting folks that are willing to get on the front line. That's a big part of what we're trying to do. 

Shiv: I love that. One of my hopes moving forward is that, as a society we not only invest more in public health and these trends that we've talked about in the last 30 minutes, but also a lot of other countries fund their health professionals. The median debt of a medical student graduating in the U.S. is $200,000 dollars. That's not a way to help encourage people to go into the field. 

So, is there anything else that you'd like our audience to know about you or Clinical Solutions or LexisNexis before we let you go on with the rest of the day? 

Josh: If you're not familiar with Clinical Solutions or the broader Elsevier health business, come check us out. We're putting a lot of innovation into the tools that we put out there for students and for professionals. New additions like Shadow Health, Osmosis, Complete Anatomy...these are all investments and add more value for our student communities and for our clinicians that are out there. 

That's really our mission. We're in a really unique spot to continue to innovate and continue to bring higher value. We have no shortage of ideas of greater integration into workflows, greater access, and managing from the life cycle of a first-year medical student to residency to full practicing physicians. I think we have a very exciting business and I'm hoping that all of your listeners, if they don't know us well, they get to know us better.

Shiv: Me too. That's one reason it has been a privilege to have you on the podcast. So with that Josh, thanks so much for taking the time to not only show up on our podcast but obviously for the important work you and the entire Clinical Solutions and LexisNexis teams do to raise the line and flatten the curve.

Josh: My pleasure! Thanks for having me. 

Shiv: And with that, thank you to our audience for checking out today's show. Remember do your part to flatten the curve and raise the line. We're all in this together. Take care!