.Dr. Daniel Ngui (biography and disclosures)
*With special thanks to Dr. Bonnie Dobbs, Director, The Medically At-Risk Driver Centre Director of Research, Division of Care of the Elderly, Professor, Department of Family Medicine for her support and guidance regarding research.
What I did before
Despite recent articles1,2, I had always felt uncomfortable about knowing what was the best way to screen medically at risk patients’ fitness to drive. In the past I would use a combination of history, collateral information, and other cognitive screening tests, the results from a DriveABLE exam, or referral to a medical consultant for their opinion.
What changed my practice
Since the introduction of the new 2010 BC Guide in Determining Fitness to Drive in July 2010 (see http://www.pssg.gov.bc.ca/osmv/publications/docs/2010-guide-in-determining-fitness-to-drive.pdf) and the change in the referral and reimbursement process for DriveABLE examination by the BC OSMV, I have tried to change my practice to include these new Guidelines, the use of the SIMARD MD, and referral to the OSMV for further direction.
What I do now
If I had to share the top 5 important points that I have learned about from reviewing and learning from colleagues, attending presentations, and reviewing data on assessing Driver’s Fitness, they would be:
1) With the increasing number of aging patients in our population, there is also an increasing number of dementia cases diagnosed each year3. When equated for exposure (e.g., amount of kilometers driven), increasing age4 and the presence of medical conditions5 increases fatality rates due to motor vehicle crashes, as well as at-fault crash rates respectively. Importantly, it’s not age per se, but rather the presence of medical conditions such as neurological, renal, and endocrine issues that affect driving competency. Many illnesses affect driving competency due to their impact on cognitive functioning. The new 2010 OSMV guidelines have an easy-to-use table (p.85) which identifies medical conditions which may affect cognition. There are also patient screening questionnaires which can be used in family practice.6
2) According to the current BC Motor Vehicle Act, a physician has a legal responsibility to report patients with medical conditions that affect driving ability to the OSMV. Based on case law7, physicians can be held legally liable for NOT reporting patients at risk. Finally, the current BC Motor Vehicle Act protects physicians from legal action from patients if the reporting is done in good faith.
3) In primary care, we need a short, inexpensive or free, easy to administer, easy to score and scientifically valid screening test to determine which of our medically at-risk patients would benefit from further assessment of driver’s fitness. The SIMARD MD8 is a published Screening tool for the office based Identification of cognitively impaired Medically At Risk patients which has been adopted by the OSMV as a screening test for medically at-risk drivers to be used by primary care providers. Compared to other commonly used cognitive assessment tests that we use to screen for dementia such as the MMSE9, the SIMARD MD is a better predictor of results from an on-road assessment. The use of dual cutpoints allows physicians to identify:
a. those patients most likely to fail the on-road assessment (lower cutpoint),
b. those patients most likely to pass an on-road assessment (upper cutpoint), and
c. those classified as indeterminate (in need of a DriveABLE Assessment for determination of driving competency).
Importantly, the SIMARD MD does not replace clinical judgment. Rather, the results of the SIMARD MD should be used in conjunction with clinical findings for decisions related to determination of driving competency.
4) In terms of physician reimbursement, although there are ongoing fee negotiations between the British Columbia Medical Association, Society of General Practitioners of BC, and the government, there are ways to bill either privately or publically for the Driver’s Medical Examinations10. Furthermore, if medically indicated and necessary and if the documentation and visit is sufficient, physicians can bill the age appropriate 0100 fee codes and can access the mental health planning fee code 14043. To report a patient’s SIMARD results or safety issues affecting driving, I use either the space provided to me in the comments section of the DMER forms or a standardized letter to the licensing authority11.
5) The BC College of Family Physicians, BC OSMV, and the British Columbia Automobile Association (BCAA) Traffic Safety Foundation are working to help educate family physicians as well as streamline the process for patients to have the DriveABLE examination. The BCAA Traffic Safety Foundation helps to co-ordinate these tests and the reporting of results to family physicians. However, only the OSMV has the right to revoke patients driver’s licenses. In cases where patients’ may need to go on for further tests, I provide them supportive counseling and also provide them with information and links to community resources as this is a significant loss and perceived threat to their independence 12
Billing codes: www.sgp.bc.ca
The October 2010 Billing tip is on billing of the DMER:
Drivers’ Medical Certification
1. Drivers Medicals for Patients with Medical Conditions
When completing these forms (blue stripe), the examining physician has the ability to choose to bill the patient the entire BCMA recommended rate or to bill OSMV via teleplan $75.00 and balance bill the patient the difference of the rate that they wish to set for this service. When billing for patients with medical conditions, the following fee codes are billable:
96220 OSMV Driver’s Medical Examination Report (DMER) for any driver with a known or possible medical condition (may bill part to OSMV via teleplan)
96221 OSMV Diabetic Driver Report-stand alone (no DMER): Diabetic Driver Report for commercial drivers with diabetes – known medical condition (may bill part to OSMV via teleplan)
96222 OSMV Diabetic Driver Report sent out with DMER: Diabetic Driver Report for commercial drivers with diabetes – known medical condition (may bill part to OSMV via teleplan)
2. Drivers Medicals For Patients 80 years of age and over (yellow stripe)
This form is completed when determining medical fitness for driving for patients 80 years and over.
3. Drivers Medicals for other categories (Class 1, 2 & 3) (yellow stripe)
This form is completed when determining medical fitness for patients who have applied for or for continuation of Class 1, 2 or 3 Drivers Licenses.
When determining the medical fitness of patients presenting with either of the forms with a yellow stripe, nothing is billable directly to MSP or OSMV. The patient, or in some cases their employer, is responsible for payment for this service. The fee code for this service is dependent on the nature of the examination requested by OSMV. If a full physical examination is requested and provided, then the 00055 fee is billed. In the case of those patients where a limited examination is requested and provided, the 00056 fee is the appropriate billing.
00056 Driver’s License – limited exam.
00055 Driver’s License – full exam
References: (Note: Article requests might require a login ID with the BC College of Physicians website or UBC)
1) D Hogan, Which older patients are competent to drive? Approaches to office-based assessment Can Fam Physician 2005; 51; 362-368. http://www.cfp.ca/cgi/reprint/51/3/362
2) F Molnar et al, Approach to Assessing fitness to drive in patients with cardiac and cognitive conditions Can Fam Physician Nov 2010; 56; 1123-9. http://www.cfp.ca/cgi/reprint/56/11/1123
3) Rising Tide: The Impact of Dementia on Canadian Society (Alzheimer Society of Canada, 2010) http://www.alzheimer.ca/english/rising_tide/rising_tide_report.htm
4) Insurance Institute for Highway Safety. Driver fatality rate by age. Available from: http://www.iihs.org/research/fatality_facts_2006/olderpeople.html
5) E Diller et al. Evaluating drivers licensed with medical conditions in Utah, 1992-1996. DOT HS 809 023. Washington, DC: National Highway Traffic Safety Administration (1999). http://ntl.bts.gov/lib/25000/25900/25974/DOT-HS-809-023.pdf
6) The Medically At-Risk Driver Protocol Working Group. Assessing the Medically At-Risk Driver – The Medically At-Risk Driver Protocol, Tools, and Resources for Health Care Professionals. Contact www.mard.ualberta.ca
7) Freese v Lemmon, 210 NW 2d 576, 577-578, 580 (Iowa 1973)
8) BM Dobbs & D Schopflocher. The introduction of a new screening tool for the identification of cognitively impaired medically at-risk drivers: The SIMARD A Modification of the DemTect. Journal of Primary Care and Community Health, 2010, 1(2), 119-127. (View article with UBC or request it with CPSBC) SIMARD MD tool: http://www.mard.ualberta.ca/Home/SIMARD/tool.cfm
9) www.sgp.bc.a Tutorial online for information on billing DMER and other fees
11) Patient Resources/Physician Resources:
1) BCAA Traffic Safety Foundation www.driverfitnessbc.com 3020 Beta Avenue, Burnaby, BC V5G 4K4. Phone:604-298-5107 Fax:604-298-6497; Email: trafficsafety@tsf-bcaa.com
2) BC Transit 604-953-3333 or google www.bctransit.com and enter your community
3) HandyDART Program http://www.translink.ca/en/Rider-Info/HandyDart.aspx. For clients with a physical or cognitive disability who are unable to use public transit without assistance. Application available online or contact Access Transit at 778-452-2860.
4) HandyCard and Taxi Savers Program: http://www.translink.ca/en/Rider-Info/Accessible-Transit/HandyCard-Taxi-Saver.aspx. Available to clients with a physical or cognitive disability who can’t use public transit without assistance.
- HandyCard lets clients travel for the “concession” rate on public transit and a person accompanying them to provide assistance can travel for free.
- Taxi Savers are available to clients who have a HandyCard. They provide discounted rates for a taxi from any company of the clients’ choice. Application available online or contact Access Transit at 778-452-2860.
5) Volunteer Driver Program, VCH: 604-267-2678. Must be a client of VCH. Transportation for medical appointments only.
6) Provincial Based Private Companies
A) Driving Miss Daisy http://www.drivingmissdaisy.net/, 1-877-613-2479. Offers transportation at an hourly rate to medical appointments, social engagements, and other events. Services offered in selected cities across BC
B) We Care Medi-Transit www.wecarehealth.com, 604-264-9003. Offers transportation at an hourly rate to medical appointments, social engagements, and other events. accompany clients by taxi or in the service provider’s own car.
7) Lower Mainland
A) Special Needs Transport: www.sntransport.ca, 1-800-768-0044. Door to door service for medical appointments or social engagements.
B) Veterans Independence Program: http://www.servicecanada.gc.ca/eng/goc/vip.shtml, 1-866-522-2122. Must be a veteran registered with Veterans Affairs Canada (or provide care to someone who is). Offers transportation for shopping, banking, visiting friends, etc.
C) Alzheimer’s Society of BC Dementia Helpline, Tuesday to Friday, 10am-4pm, 604-681-8651 or 1-800-936-6033, supportline@alzheimerbc.org
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It is much more reasonable to road test more people that i have previously felt uneasy about their abilities driving. Most people have insight into their capabilities but useful to have a fomal testing in place .
I find this nugget still too complicated.
Things must be simplified further if the bulk of practising GP’s will devote a greater mental commitment to this in an already overloaded day—sorry.
I think that periodic, updated Road Testing should be mandatory for ALL DRIVERS, based both on age and medical condition. We as doctors have to provide evidence of ongoing competency, as do pilots and others with such privileged responsibility in our society. Costs of such a road test should be paid in full, or at least part, by the driver, to save costs to the OSMV. Predictive statistics, as alluded to by the author above, already exist to help with determining who needs to be regularly tested. This may seem like an infringement on driver’s confidential information, but driving is a privilege, not a right. Costs incurred by such a road test could be reasonable.
GP’s need to be able to identify patients whose health issues may impact negatively on driving ability–this alludes to MEDICAL FITNESS TO DRIVE. However, I think it folly that GP’s should have to take on the responsibility of determining ABILITY TO DRIVE, or a supposed “likelihood” of this. What are we doing here- taking on more legal liability in an area for which we are not trained as experts ? Count me out.
I welcome others’ thoughts on this.
Jeff Dresselhuis
As an active GP, I get more and more uncomfortable, like teachers, that progressively more is placed on the shoulders of GP’s to sort out with little back-up resources to address more complex problems of modern life,e.g. the hoops to access dementia medications, etc. This area, capacity to drive, is another fraught with complex issues, incl. declining patients’ functions with age. I do what I can ascertain as best as possible, likely my accuracy is higher the longer I have known the patient, and if I have any strong feelings within the very short office visit I can afford to establish safety on the road, I then indicate my recommendation to “road test.” The responsibility for the OSMV is to heed this, and to get on and test that individual in real time on the road with a more expert assessor for the crucial elements to allow continuance for this privilege to drive. There also should be a wider forum for input from more stakeholders on this difficult issue,incl. members of the public. Better policy and framework should result. I heartily agree with my colleague, the task for overloaded GP’s is to keep it simple.
J. de Couto
IT’S TOUGH TO TAKE AWAY A PERSON’S INDEPENDANCE SOMETIMES BUT FOR THE SAKE OF INCREASED SOCIETAL ACCIDENT VICTIMS WE MUST. I HAVE LOST A FEW PATIENTS DOING THIS BECAUSE THEY JUST DID NOT UNDERSTAND AND FELT RESENTFUL OVER BEING TESTED. THE USUAL COMPLAINT IS “BUT I’VE NEVER HAD AN ACCIDENT”
I THINK THESE TESTS ARE USEFUL
I have downloaded the pdf file and have found the table useful as a guide. still a fairly unwieldy document, however.
have downloaded the pdf and find the table useful.
Can you please send me the Physician’s Guide criteria for visual acuity for 80 year old Driver’s Medical Examination.
Chapter 21 of http://www.drivesafe.com/2010%20BC%20Guide%20in%20Determining%20Fitness%20to%20Drive.pdf
I wanted to add my two cents to the issue of reportability. After medical school I was under the impression that we have to report those who have medical conditions that impact their ability to drive. In speaking with the Office of the Superintendent of Motor Vehicles, and carefully reading the form they distribute to physicians for reporting at risk patients, I learned that you can only report someone if they 1. have a condition that affects their ability to drive and 2. you have knowledge that they are continuing to drive despite medical advice to the contrary. I was told that the College is very explicit about this, we cannot violate patient confidentiality and report, for example, someone with a seizure disorder, if they agree not to drive after being advised not to. Intuitively this makes sense, if someone agrees not to drive, how is it possibly defensible that we breach their confidentiality in the interests of public safety when there is no basis for suspecting that public safety is compromised? Please share your comments and experiences.