EXECUTIVE SUMMARY

The objectives of this project were as follows:

1. To document the activities of the Medical Advisory Boards (MABs) and/or medical review units in the 50 United States plus the District of Columbia with respect to determining fitness to drive.
   
   
2. To determine which activities currently applied by one or more jurisdictions deserve priority for consideration as recommended strategies, and how to implement them.
   

The research products include reports summarizing key project activities, described below, plus recommendations for licensing agencies for the identification, assessment, and disposition of drivers with medical conditions and functional impairments, and related customer service goals.

The information obtained about medical review practices in the 51 driver-licensing agencies in the United States was obtained through requests of licensing officials to complete a survey, and then to participate in a follow-up telephone interview with the project principal investigator at TransAnalytics to clarify and expand the responses. The survey was developed jointly by the American Association of Motor Vehicle Administrators (AAMVA), the National Highway Traffic Safety Administration (NHTSA), and TransAnalytics project staff. The data collection instrument was designed using the information about drive-licensing medical review practices presented in AAMVA (1999) and Petrucelli and Malinowski (1992) as a starting point.

The survey was mailed by AAMVA, under cover signed by the AAMVA senior vice president of the Programs Division. Survey respondents were asked to mail forms, guidelines, and statutes used in their medical program operations. As surveys were received by the project principal investigator, quantitative data were entered into summary tables and qualitative data were reviewed for thoroughness. Survey respondents were then telephoned by the principal investigator, and asked to provide more detail for identified survey questions. Information obtained from the three sources (telephone conversations; the written survey responses; and State guidelines, procedures, and statutes) was used to produce a narrative detailing the procedures employed in each jurisdiction for dealing with drivers who have functional impairments and medical conditions. The draft narratives were e-mailed to the survey respondents, who reviewed the information for errors or omissions. Respondents’ comments were incorporated into the final narratives, which along with three appendices of summary tables, comprise the project deliverable titled, Summary of Medical Advisory Board Practices in the United States. This research product is posted on AAMVA’s Web site at the following address:

www.aamva.org/drivers/drvProblemDriversMedicalAdvisoryBoardPractices.asp.

An in-depth study was conducted next, to determine which activities currently applied by one or more driver-licensing agencies in the United States deserve priority for consideration as recommended strategies, and to provide suggestions that may facilitate the implementation of the recommended strategies. Two activities were undertaken to assist in this determination:

1. A qualitative summary and comparison (“Relative Value Assessment”) of medical review program activities in the United States.
   
   
2. The identification of barriers to implementing specific, selected practices, and strategies to overcome those barriers.
   

The first of these activities involved 45 of the 51 licensing jurisdictions, sampled through a mailed survey to key licensing officials and medical staff. The second was accomplished through a 1½-day meeting held in Washington, DC, that included representatives from NHTSA and AAMVA; TransAnalytics project staff; and medical review staff from a subset of States chosen with the assistance of NHTSA and AAMVA. The 11 jurisdictions represented at the meeting included: the District of Columbia, Florida, Iowa, Maryland, North Carolina, Ohio, Oregon, Utah, Virginia, Washington, and Wisconsin.

The Relative Value Assessment (RVA) exercise involved an assignment of weights among related groups of potential components of a medical review program, to determine how important each component is in relationship to the other components in the group. Representatives from all 51 jurisdictions sampled in the earlier survey conducted in this project were contacted again through AAMVA with a request to participate in the RVA exercise. As the first step in developing the RVA, medical review program components were identified as viable candidates for driver medical review recommended strategies. This was done through review of the project deliverable titled Summary of Medical Advisory Board Practices in the United States by the TransAnalytics principal investigator and senior analyst. Sixty-four candidate recommended strategies were identified. These components were arranged in a hierarchy, moving from the most general to the most specific. Respondents were asked to assign weights to subsets of medical review program components, at each level of the hierarchy. Instructions emphasized that when assigning relative values to each set of components, respondents should consider only how important each component element would be to the success of a model medical evaluation program, without regard to current feasibility of implementation.

Licensing agency medical review department personnel in 45 jurisdictions completed and returned RVA exercises. Mean weightings were calculated and were used to help pinpoint which components are considered most important to the effectiveness of a model medical review program. Components with high weightings were used as the starting point in discussions with licensing agency personnel and NHTSA and AAMVA representatives at the 1½-day meeting to identify recommended strategies and barriers to their implementation.

The meeting began with a brief overview of project activities conducted to date and a discussion of the RVA exercise outcomes. The meeting then moved into a round-table format with discussions about what constitutes recommended strategies among the 64 components rated in the RVA and what legislative and budgetary barriers could preclude implementation.

A true consensus regarding recommended strategies for most medical program components discussed at the meeting was rarely achieved; however, substantial agreement among participants was reached on the following points:

• A Medical Advisory/Review Board is a necessary component of a medical review program. Each jurisdiction should have an MAB staffed with physicians to provide advice to DMV medical review department staff regarding licensees’ fitness to drive.
  
• The role of the MAB should include review of individual cases for fitness to drive determinations (as opposed to a board that only hears appeals once a license has been denied by the DMV) and development of medical criteria/guidelines for licensing.
  
• Case review and initial licensing recommendations should be provided by individual MAB members, as opposed to requiring consensus by a panel of board members.
  
• 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.
  
• Physicians serving on an MAB should be compensated. The best scenario is to employ physicians as full-time DMV staff members. If members cannot be employed as full-time DMV staff because of cost constraints, then they should serve as paid consultants to the DMV. Compensation should be commensurate with physicians’ hourly rates (and not the $6 per case reviewed or the $25 per diem rate indicated in some State DMV statutes).
  
• Medical/functional guidelines should be used to treat drivers with consistency, but should not replace case review by MAB physicians for more complicated cases. Functional Ability Profiles are useful when administrative personnel are making licensing decisions based on information received in treating physicians’ medical reports.
  
• The rules written for medical review of drivers should not be in statute, but should be in the Code of State Regulations, so that changes can be made quickly as new medical data become available.
  
• National medical/functional guidelines for driver licensing should be developed in close consultation with the medical community, and adopted by States.
  
• The AMA/NHTSA Physician’s Guide for Assessing and Counseling Older Drivers is a useful starting point for developing National guidelines.
  
• Drivers should be required to appear in-person for license renewal when they reach a certain age, and the renewal cycle should be shortened based on driver age.
  
• Drivers should be required to self-report medical conditions for initial and renewal licensure.
  
• Physicians who report drivers in good faith (whether voluntarily or by mandate) should be immune from liability by their patients (Note: physician-reporting requirements and confidentiality of reports could not be agreed upon).
  
• The AMA/NHTSA Physician’s Guide for Assessing and Counseling Older Drivers should be used to educate physicians about medical/functional conditions and driving safety. Physicians should receive Continuing Medical Education (CME) credits for participation in the training.
  
• Continuing education for police officers in identifying potentially at-risk drivers with medical conditions and functional impairments, and procedures for referring drivers to the DMV for reevaluation, should be a priority activity for the DMVs and police departments.
  
• Consideration should be given to the use of functional screening at license renewal for drivers over a specified age to identify drivers with impairments. Where time and budget constraints limit the ability of its application within the DMV for the renewal population, its use should be considered for the population of reexamination drivers (drivers referred into the medical program by some mechanism). DMVs that cannot implement it on a designated population of renewal or reexamination drivers should join with an approved/credentialed outside organizations/associations to provide such screening and relay the results to the MAB.
  
• Customized/restricted licenses should be issued to allow drivers to maintain driving privileges under safe conditions (i.e., daytime, speed-restricted, area-restricted).
  
• Drivers with mild dementia who are deemed fit to retain driving privileges should be required to undergo reexamination driving tests at 3- to 6-month intervals, and should be required to take and pass multiple road tests for each reexamination.
  
• First-time DUI/DWI offenders should undergo review by the MAB/medical review department for an assessment of chemical dependency and fitness to drive (as opposed to having their cases disposed of through administrative action only or waiting for multiple DUI/DWI offenses to trigger medical review) based on statistics indicting that they have driven under the influence at least 200 times before their first legal pickup, 80-85 percent of such first-time offenders have an alcohol dependency problem, and 1 out of 3 first-time offenders will recidivate.
  
• The mission of DMVs should be expanded beyond the traditional role of ensuring public safety, to supporting the continuing safe mobility of drivers with medical conditions and functional impairments.
  
• The opinions of driving-rehabilitation specialists are important in the determination of fitness to drive. 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.
  
• Lists of services provided by DMVs for counseling, education, remediation, and retraining should be community-based (locally-based and not State-based).
  

Conclusions from the meeting with experts and outcomes from the RVA exercise serve as the rationale for development of recommended strategies for the identification, regulation, and continuing safe mobility of drivers with medical conditions and functional impairments.

This report summarizes the activities conducted in this project. Recommendations for a model medical review program—given realistic constraints—are presented at the end of this report. It should be noted that, while this report includes recommendations for recommended strategies, and attempts to identify key barriers to their implementation, it was beyond the scope of this project to address any timelines for implementing recommended practices. Also, while participating physicians advised the project team that State attorneys general have in some cases ruled that a Motor Vehicle Administration/Department of Motor Vehicles is exempt from the Health Insurance Portability and Accountability Act (HIPAA) to the extent that the public welfare depends upon its medical review of drivers, this report does not explicitly address the issue of whether compliance with this or other regulations will or will not be an issue in a given jurisdiction.