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RECOMMENDATIONS

The following recommendations for components of a model medical review program were developed through consideration of the results of the relative value assessment exercise and expert panel meeting conducted in this project. These recommendations are intentionally broad in scope, referencing program or policy initiatives that may fall beyond the jurisdiction of a DMV or DOT; demand resources that are not presently available; and in some instances, in some jurisdictions, even require statutory change. This approach is offered as a first step toward what must be a long-term solution for preserving personal mobility while protecting public safety in a significantly aging population. Further, it recognizes that ensuring medical fitness to drive will depend upon an active and effective partnership between licensing agencies, physicians and other health professionals.

It must be emphasized that the Model Program components presented below serve as recommendations; they do not define or imply a requirement or standard of practice for any licensing agency.

1. It is recommended that each licensing agency create a Medical Advisory Board (or equivalent organizational unit under another name) with roles and responsibilities as described below.

1.a. At a minimum, the roles of the MAB should include:
1.a.1. Review of individual cases (e.g., review of medical reports, in-person interview, video interview) to make medical/functional fitness-to-drive determinations and licensing recommendations to the DMV; and
1.a.2. Development of medical criteria/guidelines for licensing.
1.b. Case review and initial licensing recommendations should be provided by individual board members, as opposed to requiring consensus by the entire board or a panel of board members.
1.c. The use of in-person and video interviews between MAB physicians and drivers under review should be explored to assist in making an initial fitness-to-drive determination.
1.d.  Where feasible, MAB physicians should be employed by the DMV, in full-time or part-time staff positions.
1.e. Where DMV staff-position employment is not feasible due to cost constraints, MAB physicians should serve as paid consultants to the DMV, and should be compensated at a rate commensurate with rates obtained through private practice or hospital employment.
1.f. To prevent the exclusion of specialists other than physicians (e.g., an occupational therapist or registered nurse) from serving on the board, statutes should not be written that define or limit the medical specialties or types of professionals who comprise the MAB.
2. It is recommended that uniform National medical/functional guidelines for driver licensing be developed for adoption by the 51 licensing agencies in the United States.
2.a. As the first step toward establishment of a national association of Medical Advisory Boards, AAMVA and NHTSA should work cooperatively to create Medical Review Task Groups to develop uniform guidelines for medical/functional fitness to drive for operators of passenger vehicles, for adoption by States.
2.b. The Medical Review Task Groups should consist of physicians and other medical professionals, and driver licensing administrators from a variety of licensing agencies across AAMVA’s regions, for the purpose of drafting a set of National guidelines for licensing drivers with medical conditions/functional impairments.
2.c. The Medical Review Task Groups should meet annually and update guidelines to keep them current with the latest knowledge.
2.d. Guidelines should be drafted for all conditions that affect safe driving ability. These include vision, losses of consciousness/seizure disorders, medical conditions affecting multiple body systems (e.g., pulmonary, cardiovascular, neurological, musculoskeletal, learning/memory, psychiatric, etc.), and for substance abuse disorders.
2.e. The Federal Department of Transportation should promulgate the National guidelines.
2.f. The AMA/NHTSA Physician’s Guide for Assessing and Counseling Older Drivers should be used as the starting point for developing National guidelines.
3. The rules for medical review of drivers should not be placed in State statute, but should be in the Code of State Regulations, so that changes can be made quickly as new medical data become available.
4. For assessment of chemical dependency and fitness to drive, it is recommended that all cases (including drivers convicted of DUI/DWI for the first time) be routed through the Medical Advisory Board, as opposed to allowing disposition of the case through administrative action only.
5. It is recommended that medical/functional guidelines be employed by a licensing agency, to treat drivers with consistency.
5.a. Medical/functional guidelines used by non-medical administrative personnel to make licensing determinations should not replace case review by MAB physicians for more complicated cases.
5.b. The use of Functional Ability Profiles is recommended when non-medical administrative personnel are making licensing decisions based on information received in treating physicians’ medical reports.
6. To protect public safety while balancing individual quality of life and protecting the patient/physician relationship, it is recommended that mandatory physician reporting laws be implemented, as follows:
6.a. Physicians should be required by law to report drivers with cognitive and functional impairments that are:
  • Severe to a degree that preclude the safe operation of a motor vehicle and uncontrollable (e.g., through medication, therapy or surgery; or by driving device or technique); OR
  • Severe to a degree that preclude the safe operation of a motor vehicle and controllable, but the patient does not comply with the physician’s recommendations for treatment or for restricting driving.
6.b. Physicians who report drivers in good faith to the DMV should be immune from civil or criminal liability.
6.c. Although physicians should advise their patients when they report them to the DMV, the DMV should keep physician reports confidential.
7. The DMV should accept reports of potentially at-risk drivers from physicians and other medical providers, law enforcement, social services providers, friends, families, and other concerned citizens.
7.a. Physicians, other medical specialists, and law enforcement should be considered as expert sources, and as such, reports of at-risk drivers that originate from these sources need not be followed up by investigators to confirm the validity of the report before a licensing action is made or before a driver is required to undergo reexamination (medical history, vision, knowledge, and road test).
7.a.1. When a report from an expert source indicates that a driver had a loss of consciousness, a temporary emergency suspension should be issued, where an investigator is sent to the driver’s home to pick up the license until the MAB can review the case. The drivers should then be required to have their physicians complete and return medical history forms to the MAB within 30 days, based on an examination that is no older than 3 months. Failure to have the forms completed and submitted should result in the emergency suspension becoming indefinite (or until forms are received, the case undergoes MAB review, and a favorable fitness-to-drive disposition can be made).
7.a.2. When a report from a physician indicates that a driver has a cognitive or functional impairment so severe and uncontrollable the driver is unable to drive safely, or a driver does not comply with treatments and as such is unable to drive safely, a temporary emergency suspension should be issued, where an investigator is sent to the driver’s home to pick up the license until the MAB can review the case. The driver should then be required to have the physician complete and return medical history forms to the MAB within 30 days, based on an examination that is no older than 3 months. Failure to have the forms completed and submitted should result in the emergency suspension becoming indefinite (or until forms are received, the case undergoes MAB review, and a favorable fitness-to-drive disposition can be made).
7.a.3. When a report from an expert source does not involve loss of consciousness, or does not involve impairments as indicated in 7.a.2, drivers should be required to have their physicians complete and return medical history forms to the MAB within 30 days, based on an examination that is no older than 3 months. Failure to have the forms completed and submitted should result in an indefinite license suspension (or a suspension until the forms are received, the case undergoes MAB review, and a favorable fitness-to-drive disposition can be made).
7.b. Drivers identified as potentially at-risk through reports submitted to a licensing agency by non-expert sources should be required to have their physicians complete and return medical history forms to the MAB within 30 days, based on an examination that is no older than 3 months. Failure to have the forms completed and submitted should result in an indefinite license suspension (or a suspension until the forms are received, the case undergoes MAB review, and a favorable fitness-to-drive disposition can be made).
7.b.1. Anonymous reports received by the DMV from non-expert sources should be followed up by DMV investigators to ensure validity of the report, before a driver is required to undergo reexamination.
7.b.2. Where resources preclude follow-up of anonymously submitted reports, DMVs should not accept reports that do not include the reporter’s name, address, and signature attesting to the truth of the report.
7.c. The DMV should allow reports from non-expert sources to remain confidential. The DMV should be exempt from open-records laws in States, where a truly at-risk driver would otherwise be allowed to retain driving privileges should a case be dismissed from court as a result of a confidentiality clause.
8. It is recommended that the DMV, in consultation with State and/or National medical associations provide training to educate physicians about the relationship between medical/functional conditions and driving safety, the State’s reporting requirements, and how to counsel patients to adjust driving habits or seek alternative transportation.
8.a. The AMA/NHTSA Physician’s Guide for Assessing and Counseling Older Drivers should be used to train physicians.
8.b. Physicians should receive CME credits for participation in the training.
8.c. Physicians should be required to complete a periodic CME in driver medical education.
8.d. Treating physicians should be educated about the role driving specialists play in assessing fitness to drive and providing rehabilitation and retraining. Mechanisms should be put into place for DMVs and treating physicians to refer drivers to these specialists.
9. It is recommended that the DMV provide training to law enforcement officers in identifying drivers potentially at-risk due to medical conditions and functional impairments, and procedures for referring drivers to the DMV for reevaluation.
10. It is recommended that drivers be required to appear in person (eliminate renewal by mail) for license renewal when they reach a designated age threshold. An age in the range of 70 to 75 is most commonly cited in this regard.
10.a. Drivers renewing their licenses who meet or exceed a designated age threshold (as per above) should be required to undergo vision screening, knowledge testing, and functional abilities screening. For jurisdictions where functional ability screening is not feasible within the DMV, a partnering relationship should be established with an approved/credentialed outside party to perform functional screening.
10.b. The renewal cycle should be shortened to 2 years when drivers reach a designated age threshold (as per above), which is the limit at which functional screening measures appear to lose their value as predictors of crash risk.
11. It is recommended that vision screening be implemented for all renewing drivers 40 and older.
12. It is recommended that license examiners be trained in how to observe signs of impairment, and in what procedures to follow when they suspect a driving impairment.
12.a. When license examiners observe behaviors that lead them to suspect that a customer is cognitively or functionally impaired, or may have medical conditions that prohibit safe operation of a motor vehicle, provisions should be available for the examiner to conduct knowledge testing, vision and other functional abilities testing, and if appropriate, road testing. The MAB should develop procedures for license examiners to know when to refer drivers to their treating physicians.
12.b. When functional abilities testing by the licensing agency is not feasible, license examiners should refer drivers to their treating physicians, or to an occupational therapist, or other qualified driving assessment specialist for an examination which may result in a case review by the MAB.
13. It is recommended that original applicants and all renewal applicants be required to self-report medical conditions on the licensing application form.
13.a. The licensing application form should contain a list of medical conditions that may affect safe driving performance (ref. Maryland, Utah, Wisconsin).
13.b. After being licensed, drivers should be required by law to notify the DMV within 30 days if they have had a seizure or loss of consciousness.
14. It is recommended that customized/restricted licenses be issued as required to allow drivers with medical conditions/functional impairments to maintain driving privileges under safe conditions (e.g., daytime, speed-restricted, area-restricted).
15. It is recommended that drivers who are issued geographically restricted licenses be required to undergo periodic road testing during the license cycle, to ensure that functional ability has not declined to the point that the operating privilege should be withdrawn.
16. It is recommended that drivers with mild dementia who are deemed fit to retain driving privileges be required to undergo reexamination drive tests at 3- to 6-month intervals, and also be required to take and pass multiple (2 or 3) road tests administered at least a week apart for each reexamination to maintain their driving privileges. This protocol will minimize the “good-day/bad-day effect” that is common among drivers with dementia.
17. It is recommended that the mission of DMVs be expanded beyond the traditional role of protecting public safety, to supporting the continuing safe mobility of drivers with medical and functional impairments.
17.a. Lists of services provided by DMVs for counseling, education, remediation, and retraining should be community-based (locally based and not State-based).
17.b. The DMV should take an active role in educating the public about medical and functional fitness to drive, its State’s reporting requirements, tips to help drivers drive safely longer, and resources for assessment, remediation, and treatment. NHTSA, AAMVA, and other DMVs should be contacted for assistance in the public information and education effort.


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