Summary of Medical Advisory Board Practices in the US - MD Support

453 Pages·2003·2.01 MB·English

Summary of Medical Advisory Board
Practices
in the United States

June 18, 2003

TransAnalytics, LLC
Table of Contents

Page

Foreword and Acknowledgements...................................................................................................1
Alabama ...........................................................................................................................................2
Alaska ..............................................................................................................................................7
Arizona...........................................................................................................................................13
Arkansas.........................................................................................................................................19
California.......................................................................................................................................23
Colorado.........................................................................................................................................32
Connecticut....................................................................................................................................37
Delaware........................................................................................................................................53
District of Columbia.......................................................................................................................61
Florida............................................................................................................................................67
Georgia...........................................................................................................................................77
Hawaii............................................................................................................................................82
Idaho ..............................................................................................................................................87
Illinois............................................................................................................................................92
Indiana..........................................................................................................................................101
Iowa..............................................................................................................................................107
Kansas..........................................................................................................................................114
Kentucky......................................................................................................................................120
Louisiana......................................................................................................................................126
Maine ...........................................................................................................................................133
Maryland......................................................................................................................................140
Massachusetts...............................................................................................................................152
Michigan......................................................................................................................................164
Minnesota.....................................................................................................................................170
Mississippi...................................................................................................................................179
Missouri.......................................................................................................................................184
Montana .......................................................................................................................................190
Nebraska.......................................................................................................................................195
Nevada.........................................................................................................................................201
New Hampshire............................................................................................................................207
New Jersey...................................................................................................................................211
New Mexico.................................................................................................................................216
New York.....................................................................................................................................220
North Carolina..............................................................................................................................226
North Dakota................................................................................................................................236
Ohio..............................................................................................................................................241
Oklahoma.....................................................................................................................................248
Oregon..........................................................................................................................................256
Pennsylvania................................................................................................................................264
Rhode Island ................................................................................................................................271
South Carolina..............................................................................................................................276
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Table of Contents (Continued)

Page

South Dakota................................................................................................................................284
Tennessee.....................................................................................................................................289
Texas............................................................................................................................................294
Utah..............................................................................................................................................310
Vermont.......................................................................................................................................318
Virginia........................................................................................................................................322
Washington..................................................................................................................................330
West Virginia...............................................................................................................................339
Wisconsin.....................................................................................................................................345
Wyoming......................................................................................................................................356

Appendix A: Data Collection Tool..............................................................................................363
Appendix B: Survey and Telephone Interview Respondents......................................................379
Appendix C: Summary Tables for All Jurisdictions....................................................................385
Appendix D: Summary Tables for Jurisdictions with MABs......................................................417
Appendix E: Summary Tables for Jurisdictions without MABs.................................................441

List of Tables
Table Page

1 Guidelines used in Delaware to identify functional limitations.............................56

2 Driver impairment profile used in North Carolina for seizures...........................234

3 Functional ability profile used in Utah for private-vehicle drivers with
Epilepsy................................................................................................................316

4 Wisconsin DMV standards used to determine functional ability for driving......348

List of Figures
Figure Page

1 Functional ability profile for seizures and unexplained alterations of
consciousness used by the Maine Bureau of Motor Vehicles..............................138
2 Overview of functional ability profiles used in Utah, showing principal
requirements for each level, for each medical category used to define a person's
physical, mental, or emotional health...................................................................315
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List of Figures (Continued)
Figure Page

3 Washington Driver Field System input screen.....................................................338

4 Washington Driver Field System status screen....................................................338

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FOREWORD AND ACKNOWLEDGEMENTS

The information presented in this report was obtained through requests of licensing
officials to complete a survey developed jointly by the American Association of Motor Vehicle
Administrators (AAMVA), the National Highway Traffic Safety Administration (NHTSA), and
project staff, and through follow-up telephone calls made by the project Principal Investigator to
clarify and expand the responses. The data collection instrument was designed based on a
review of the information presented in Petrucelli and Malinowski (1992) Status of Medical
Review in Driver Licensing: Policies, Programs, and Standards (Report No. DOT HS 807 892).
The survey is presented in Appendix A.

The Association of Motor Vehicle Administrators (AAMVA) provided assistance in the
identification of the most appropriate Licensing Agency contacts to whom the survey was
directed, with input from the Governor’s Highway Safety Representative in each jurisdiction.
Identification of survey respondents proceeded in the following manner. AAMVA mailed a
letter to their primary driver license contact in each jurisdiction that explained the project
objectives, and provided advanced notice that his or her assistance would be requested in the
upcoming months. A request was made in the letter to contact AAMVA and provide the name of
the person in the motor vehicle agency who would have the most knowledge regarding the day-
to-day activities surrounding drivers with medical conditions and functional impairments, if the
position of the addressee was too far removed from such activities.

Project staff mailed letters to each of the 51 Governor’s Office of Highway Safety
Representatives, advising them of the project objectives, and requesting that they also provide
contact information for the most appropriate contact in their State’s Licensing Agency for
assistance in completing the survey. New contact information was reviewed by AAMVA, who
maintained and updated the list of contacts for the project. Once the list of contacts was
finalized, a cover letter for the survey was drafted by AAMVA and project staff that explained
the organization of the survey; provided a checklist of additional information that should be
returned with the completed survey (e.g., license application forms, medical and visual forms;
and Agency guidelines, procedures, and statutes); and provided a due date for survey completion
and return to the contractor. The finalized list of survey respondents is presented in appendix B.

The survey was mailed by AAMVA, under cover signed by Michael R. Calvin, Senior
Vice President, Programs Division. As surveys were received, quantitative data were entered into
summary tables (see appendixes C, D, and E), 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 from the telephone
conversations was recorded manually, and used with the written survey responses to produce a
narrative detailing the procedures used in each jurisdiction for dealing with drivers who have
functional impairments and medical conditions. Survey respondents were asked to mail forms,
guidelines, and statutes used in their medical program operations. These materials were
reviewed and incorporated into each State summary. The draft summaries were then e-mailed
back to the survey respondents, who reviewed the information for errors or omissions.
Respondents’ comments were incorporated into the final summaries, which are presented in the
pages that follow.
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Alabama

Organization of the Medical Program

Driver licensing in Alabama is administered by the Department of Public Safety (DPS).
Alabama has a Medical Advisory Board that was created in 1979, and is comprised of 18
members representing the following medical occupations: optometrists, ophthalmologists,
cardiologists, family practice physicians, internal medicine, neurology, orthopedics,
psychiatrists, psychologists, and endocrinologists. The head of the Board is a psychiatrist.
Members are volunteer consultants to the DPS, who work in private practice. They are
nominated and appointed by the Director of Public Safety; there is no limit to their term of
service. Board members meet annually as a group, and use email and regular mail to interact for
disposition of cases, on a case-by-case basis. Although Board members’ identities are public,
they are immune from legal action. Records and deliberations of the board are confidential,
except that the driver may request a copy, and reports may be admitted as evidence in judicial
review proceedings.

The Board performs or has performed a variety of activities for the DPS. It advises the
DPS on medical criteria and vision standards for licensing; it assists in developing standardized,
medically acceptable forms; it apprises the Licensing Agency of new research on medical fitness
to drive; it advises on procedures and guidelines; and Board physicians review and advise on
individual cases. For this later activity, the Board physicians generally perform paper reviews;
however, occasionally they will screen or assess abilities needed to drive safely (hearing, for
example, for a CDL driver), particularly when an appeal is being made. Licensing decisions may
be based on the recommendation of the entire Board, by a subset of the Board members, or by
recommendations made by a single member.

The DPS has an internal medical unit that consists of five civilian employees who have
been trained (on the job) to evaluate the medical forms. These employees are dedicated to
medical review activities and apply State laws governing medical qualifications for driving to
make licensing decisions (Alabama Department of Public Safety, Administrative Code, Chapter
760-X-20), as well as physician recommendations for restricting the driving privilege.

Identification of Drivers with Medical Conditions and Functional Impairments

Application Form

Drivers with functional impairments or medical conditions come to the attention of the
Licensing Agency in several ways. First-time applicants are required to respond to two
questions about the presence of medical conditions when they complete their original license
application. The first question asks whether the applicant has ever experienced any medical
condition that affected his or her ability to drive safely, and lists the following conditions: brain
or head injury; heart; lungs; seizure disorder; insulin dependent diabetes; mental; muscle or
nerve; stroke; addiction to alcohol or drugs; altered consciousness; and missing limb(s). The
second question asks whether the applicant is being treated for any of the listed conditions. This
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is the only time applicants report to the DPS in person, or complete such an application, unless
they are required to take a road test as part of a reexamination. If an applicant answers “Yes” to
any of the medical questions, he or she would be required to have a medical examination
performed by the physician, who would provide medical information to the DPS.

Renewing drivers go to a probate office for photo license renewal every 4 years; no tests
are required for renewal, no medical questions are asked, and no observations of functional
impairment are noted by the clerks who process renewals.

Vision Screening and Vision Standards

Drivers’ visual capabilities are assessed upon original licensure, and then again only if
they are referred to the Department for reexamination. Renewal drivers do not undergo vision
screening. Visual standards for licensing are 20/40 acuity with both eyes and a horizontal
temporal field of at least 110 degrees from the center. Original applicants and reexamination
drivers who have uncorrected visual acuity of less than 20/40 in each eye, but at least 20/50 in
one eye and/or a visual field of less than 100 degrees are referred to a vision specialist for
examination and an advisory recommendation. The person will also complete a driving
evaluation, and may be restricted to driving with outside mirrors or driving during daylight
hours. Drivers who do not have a visual acuity of at least 20/60 or better in at least one eye, as
assessed by a vision specialist will not be licensed to drive.

Referral Sources

The Licensing Agency accepts reports of potentially unsafe drivers from police officers,
the courts, family, friends, other citizens, hospitals, occupational therapists, and physical
therapists. Anonymous reports are not accepted; a sworn affidavit must be signed by all referral
sources with the exception of medical professionals. Investigations are made for all reporting
sources (other than medical professionals) before the driver is contacted. Physicians are not
required by law to report drivers who have medical conditions to the licensing agency, but they
may report drivers on a voluntary basis. Such voluntary reports by physicians are confidential,
except that the driver may request a copy and reports may be admitted as evidence in judicial
review proceedings of drivers determined to be incompetent. Physicians who choose to report
drivers on a voluntary basis are immune from legal action by their patients.

Evaluation of Referred Drivers

Procedures

Circumstances which may require a driver to undergo reevaluation include: referral by
police, the courts, physicians, occupational therapists, friends, family, and other citizens, and
self-report of a medical condition. When the DPS receives a report of a potentially unsafe driver,
a general medical form is sent to the driver, which must be completed by his or her physician.
The physician is asked to indicate whether the patient has the ability to drive safely, and what
kinds of licensing restrictions are recommended. Completed forms are sent back to DPS
Medical Review Unit. Most referrals to the DPS for reexamination are disposed of easily by the
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Medical Unit Staff, using the medical criteria and guidelines. Cases that fall into a grey area
with regard to State law, or are out of the ordinary or of a controversial nature are referred to the
Medical Advisory Board for review. Cases are submitted to a panel of three doctors who are
specialists in the medical condition that affects the person’s ability to safely operate a motor
vehicle. MAB physicians can recommend that a road test be given by the DPS for more
information regarding the driver’s ability to safely operate a motor vehicle, and they can
recommend license restrictions, suspensions, and periodic reexaminations. Road testing is
frequently recommended for older referred drivers.

Medical Guidelines

Medical standards have been developed for the following medical conditions: alcohol and
other drug use; conditions affecting cardiovascular function, conditions affecting cerebrovascular
function, conditions affecting endocrine function, conditions affecting musculoskeletal function,
conditions affecting neurological or neuromuscular function; conditions affecting peripheral-
vascular function; conditions affecting psychosocial, mental, or emotional function; conditions
affecting respiratory function; and conditions affecting sensory function. As an example of the
depth of the medical review standards, the standards for conditions affecting cardiovascular
function are presented below.

A person who applies for, renews, or holds an operator’s license shall meet all of the
following cardiovascular function criteria:

• There are no current symptoms of coronary artery disease such as unstable
angina, dyspnea, or pain at rest, which interfere with safe driving, as assessed by
a physician or determined through a driving evaluation.
• There is no cause of cardiac syncope present, including ventricular tachycardia or
fibrillation, which is not successfully controlled.
• There is not congestive heart failure that limits functional ability and is assessed
by a physician as interfering with safe driving ability.
• Any cardiac rhythm disturbances are successfully controlled.
• There is no automatic implantable cardioverter defibrillator, unless the device is
assessed by an electrophysiologist as not interfering with safe driving.
• There are no medications interfering with safe driving.
• There is no valvular heart disease or malfunction of prosthetic valves that is
assessed by a physician as interfering with safe driving.

Drivers who have had episodes of altered consciousness or loss of bodily control caused
by a neurological condition must be seizure free for the 6 months preceding license application.

Disposition

License Restrictions, Periodic Evaluations and Remediation

License restrictions are generally based on the recommendations provided by the driver’s
personal physician, and the results of a driving examination. Restrictions may include corrective
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lenses; use of a specially equipped vehicle; hearing aids; operation only during daylight hours;
restriction of the driving area; or any other restriction deemed necessary for safety purposes by
the Department.

Periodic reexaminations or medical statements are recommended for drivers with
dementia, as well as and other medical conditions that are not curable and/or are progressive,
such as diabetes and some eye diseases. Drivers with dementia are allowed to drive in Alabama,
unless their condition has deteriorated to the point where their physician indicates that they no
longer have the ability to drive safely.

Remediation of impairing conditions is not among the recommendations made by MAB
physicians, nor are drivers referred to specialists for remediation by the DPS. Drivers may elect
to have outside assessments or receive training after experiencing license restriction or
cancellation, or after falling victim to an impairing medical condition such as a stroke. However,
they must still demonstrate that they can pass the DPS road test before being licensed or having
restrictions removed.

Appeal of Licensing Actions

There is an appeal process for drivers whose driving privilege is suspended or restricted
for medical conditions or functional impairments. Persons denied a driver license or whose
license is suspended, revoked, or cancelled for medical reasons may request an administrative
hearing within 14 days of receipt of Department notification of the licensing action. The
administrative hearing is held before an independent hearing officer who is an attorney or
otherwise qualified person. Medical reports, medical literature, and the reports and
recommendations of physicians are admissible in the hearings, and it is not necessary for the
treating physician to be present at the hearing. An employee from the Medical Unit who is
familiar with the case will represent the Department of Public Safety at the hearing.

Counseling and Public Information & Education

Public information and educational materials are not made available to older drivers
explaining the importance of fitness to drive, and relating impairments to increased crash risk.
The DPS does not provide counseling to drivers with functional impairments, nor are drivers
referred to an outside resource for counseling following licensing restriction or cancellation that
may cause lifestyle changes.

Administrative Issues

Training of Licensing Employees

The Licensing Agency does not provide specialized training for its personnel in how to
observe applicants for conditions that impair their ability to operate a motor vehicle safely, nor is
specialized training provided for licensing personnel relating to older drivers.

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Medical Program Tracking System

The Licensing Agency uses an automated medical records system and automated work-
flow systems.

Barriers to Implementing More Extensive Screening, Counseling and Referral Activities.

Three barriers were identified that would inhibit more extensive screening, counseling,
and/or referral activities, including connections to alternative transportation; they are personnel,
money, and privacy.

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