From the rise of email to the digitization of health records, Flaura Winston, MD, PhD, has watched technology transform the way we treat and manage children’s health throughout her career. And in her nearly 30 years at Children’s Hospital of Philadelphia, the founder of the Center for Injury Research and Prevention (CIRP) has become known as both a brilliant physician and an academic with a vision. As her colleagues over the years would attest, Dr. Winston is a boundary-spanner when it comes to innovation — one who has the ability to connect inventions to impact, and research to society.
This year, she will share that vision as a new member of the National Academy of Medicine (NAM). Elected this fall, Dr. Winston is the 10th CHOP physician to join the NAM and one of 80 physicians to receive the honor in 2017. Since 1970, the NAM has tapped doctors and researchers who have made valuable contributions to health, medicine, and science to join their prestigious organization. The group addresses critical issues in health and science-related policy by advising both the nation and the international community.
With her lifelong work in child passenger safety, teen driving, and injury research, Dr. Winston, who also is a professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, has valuable insight to offer. When asked what she hopes to bring to the NAM, Dr. Winston recalls two key concepts that have been, in many ways, the themes of her career: First, the ability to identify “edge conditions,” which she defines as the limits of new technologies or innovations, and second, the foresight to find the most effective partners to carry research findings into society.
“I’m thrilled to be part of this auspicious organization because of the opportunity it offers to provide leadership in some of the most crucial issues facing our society from a health and safety perspective,” Dr. Winston said. “As we move into a new world where technology becomes increasingly important, we need boundary-spanners — people who can make sense of the technology and optimize it for society. I’m really fortunate that I will be able to serve in that capacity to support health in our country and be a voice for children.”
Seeing the Edge Conditions
Every technology has an edge condition, and inevitably, it’s necessary to question what responsibilities clinicians and researchers must take on to address those limits. By doing so, an innovation can make its strongest impact on society. Identifying and addressing the edge conditions has allowed Dr. Winston, with the support of her teams, to advance injury research in novel ways.
“If you look back on my career, one theme is clear: I seem to be drawn not only to identifying and optimizing technology’s benefits but also revealing its limits,” Dr. Winston said. “We need to understand these ‘edge conditions’ beyond which a given technology does not perform as intended. Technology designed for adults might not work well for children, for example. Engineers need us to provide the scientific foundation on which they can design technology with children in mind.”
The Passengers for Child Safety Program (PCPS) — a partnership between CHOP, the University of Pennsylvania, and State Farm Insurance — is a perfect example of edge conditions at work. In the mid-1990s, Dr. Winston’s work in the CHOP Emergency Department as a pediatrician-researcher brought the problem of air bags to her attention. The (then) new technology was intended to keep drivers and front seat passengers safe and indeed saved lives daily, but in July of 1995, a 20-day-old baby was dead on arrival after a survivable crash. The baby had been rushed to the emergency department at CHOP as Dr. Winston finished her residency. This was the first reported case of a child fatality from an air bag and was the harbinger for an epidemic of deaths and serious injuries to children from a life-saving technology for adults.
For those first-generation air bags, Dr. Winston said, children were the “edge conditions.” The technology at that time did not take into account that a child might sit on a front passenger’s lap or scoot forward on the front seat, both of which put the child in the path of the deploying air bag in the event of a crash. In order to safely move forward with air bag use, someone needed to fill a major gap in knowledge about child occupants in motor vehicles. When a State Farm Insurance Companies researcher came to CHOP to discuss research with Dr. Winston, she brought along Dennis Durbin, MD, MSCE, currently assistant vice president and chief clinical research officer at CHOP Research Institute. She and Dr. Durbin initiated a partnership between CHOP and State Farm that would become the nation’s only large-scale, child-focused crash surveillance data system.
By using State Farm claims data to identify more than 875,000 children involved in 600,000 car crashes and conducting in-depth on-site crash investigations and telephone interviews, the PCPS team identified the top reasons why children were injured in car crashes. PCPS went on to publish more than 80 peer-reviewed scientific papers in more than 20 journals.
For over a decade, the publication and proactive translation of PCPS research helped galvanize a sea change in state and federal safety standards and laws, and it informed new product development, test protocols, public education, and medical practice. All this action cut in half the number of children dying annually in car crashes.
Dr. Winston sees indications of the air bag crisis in today’s new technologies that have real benefits but also real limits that can pose dangers. She explained this simply by saying that we cannot “engineer out humans.” For the foreseeable future, technology — from advanced driver assistance system (ADAS) technologies to machine-learning to guide medical diagnosis — will require humans for the edge conditions that go beyond the limits of the algorithms.
“One major challenge for training tomorrow’s clinicians will be in recognizing the limits of technology and how and when to transfer control to and take control back from the machines,” Dr. Winston said. “It will be a man-machine partnership.”
It’s this background in technology, pediatrics, and human behavior that Dr. Winston plans to bring to the deliberations of the NAM as it explores issues for next generation and technology-driven medicine.
Who Needs It? The Power of Partnerships
State Farm turned out to be the perfect partner to help injury research at CHOP and Penn make a solid impact on the lives of children. This power of collaboration is yet another theme that threads through Dr. Winston’s career and a concept she hopes to contribute to the NAM.
“Few discoveries actually achieve impact in the lives of our patients,” Dr. Winston said. “The key thing that I’ve always done in my career is to think about who is going to be the end-user of the work, and I get them involved at the very beginning. When we work within silos, we’re missing the opportunities for true advances.”
Dr. Winston adds that it’s integral to identify what partners — whether they are a clinical service, a manufacturer, a legislator, or a nonprofit — can best carry findings forward to impact society. By asking who will care about their outcomes, researchers overcome what’s often called the “Valley of Death” in translational research: the gap between discovery and value.
One good example of this is Diagnostic Driving, a company spun out of CHOP in 2015 and based on decades of research. Though it began as a startup, Diagnostic Driving has accelerated into a successfully piloted business for improving driving safety with Dr. Winston as its co-founder along with Venk Kandadai, MPH. The company reached an important milestone earlier this year with a new partnership with the state of Ohio. Its compelling story, however, began when Dr. Winston identified the edge condition in current on-road driving licensing tests. Backed by her team, she then sought to find the best partners to address those limits.
In her research, Dr. Winston had observed a very high rate of young driver crashes: a 3 to 4 times increased risk of fatal crashes compared to adults in their first six months of independent driving.
“I asked, what’s missing here?” Dr. Winston said.
The answer, hidden in plain sight: Current tests did not expose individuals to the situations they might actually encounter on the road that lead to crashes. Because driving tests had to be safe for the evaluator, they missed the opportunity to assess the skills drivers need to handle serious crash scenarios.
Once they understood this, Dr. Winston and her team built and validated a virtual driving assessment software package over the course of five years. The software assessed driver safety and provided insight to personalized interventions in order to improve driving.
Next, they needed the right partners who could help the software directly address the high crash rates in young drivers. After applying for a contract with the state of Ohio to create a virtual driving test that Diagnostic Driving calls Ready Assess™ and Ohio calls the Portable Driver Simulator System, Dr. Winston and her team were approved to begin work with their new partners in January 2017.
A Stellar Example of Research Collaboration to Drive Impact
Over the course of six months, Kandadai, Dr. Winston, and their team met with subject matter experts in driver licensing for the state of Ohio — the individuals who are on the road day in and day out with the young drivers.
“We brought our evidence base and learned how to adapt to their real-world experience in order to make this product as real as we possibly can,” Dr. Winston explained. “Together we ended up with something magical: Ready Assess™.”
Ready Assess™ is already being used in a testing center where Dr. Winston has been collecting pilot study data. Furthermore, Ohio has also agreed to a two-year, nearly two-million-dollar contract to roll the software out to the entire state.
While the research breakthroughs accumulated throughout Dr. Winston’s career indeed seem magical, they also exemplify her passion and devotion to advancing children’s health and safety. Humbly, however, she said that like many of her collaborative projects over the years, receiving the NAM election is in itself, a sort of collaboration.
“There’s nothing that I could have done without all of the co-investigators and partners I have been fortunate to have worked with,” Dr. Winston said. “My whole role has always been to be a boundary-spanner and a person who is able to see far forward and to bring together teams. But without the collaboration, I could never have gotten my work done. I have received this honor because of all of the people who are behind me.”