Reporting Requirements, Confidentiality, and Legal Immunity for Physicians Who Report Medically Impaired Drivers

Key Points Question What are the state reporting requirements for physicians who report medically impaired drivers, and are confidentiality and legal immunity available to them? Findings In this cross-sectional study of all 50 US states’ Motor Vehicle Departments, only 6 US states required mandatory reporting, 3 states accepted anonymous reports, 7 states deemed physician reports confidential without exception, and 37 states granted legal immunity to reporting physicians. One-third of state Department of Motor Vehicle websites lacked instructions regarding physician reporting of medically impaired drivers. Meaning This study found variations in state reporting requirements for physicians who treat medically impaired drivers and identified several potential barriers to physician reporting.


Introduction
Physicians play an important role in assessing patients' ability to drive. 1,2Across a variety of medical specialties, including ophthalmology, emergency medicine, neurology, and primary care, physicians may encounter patients who drive despite having medical conditions that may make it unsafe to do so.Physicians have an opportunity and, in some states, an obligation to report medically impaired drivers to licensing agencies to reduce injuries and deaths from preventable motor vehicle crashes.
Physicians face a variety of logistical and ethical barriers when it comes to reporting medically impaired drivers.Physicians may fear that reporting will damage the patient-physician relationship.
They may also lack training on what types of conditions to report and whether reporting in their state is mandatory or voluntary.In addition, physicians may feel uneasy about the confidentiality of the reporting process and the potential legal ramifications if disgruntled patients pursue legal action against them.The present study aims to address these barriers and concerns.To our knowledge, the most recent peer-reviewed study on these topics was published in 2011, 3 which may predate many updates to state legal codes and Department of Motor Vehicle (DMV) websites. 4We synthesized data from all 50 US states' DMV websites, telephone calls to DMV representatives, and state laws to present a review of mandatory and voluntary physician reporting requirements, options to report anonymously, the confidentiality of physician reports, and the availability of legal immunity for physicians who report medically impaired drivers.

Methods
We identified 3 sources of information to examine the current requirements for reporting medically impaired drivers.First, to identify the state DMV websites that describe physician reporting of medically impaired drivers, Google searches were conducted with the following search terms: state name, Department of Motor Vehicles, physician, reporting, medically, impaired, and driver.Second, each DMV's telephone number was collected from these websites.Automated DMV voice messaging systems were navigated to reach DMV licensing telephone representatives who helped direct the call to the office that manages physician reporting of medically impaired drivers.Third, to identify the section of each state's legal code that describes physician reporting of medically impaired drivers, Google searches were conducted with the following search terms: vehicle, legal, law, code, department of motor vehicles, physician, reporting, medically, impaired, driver, and the state name.
The University of California San Diego institutional review board determined that this study did not require institutional review board approval as the study did not meet the definition of human participants research.This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. 5om November 1 to 30, 2022, information was collected from these sources regarding whether reporting was mandatory or voluntary, options to report anonymously, medical conditions that need to be reported, how to report, the confidentiality of reports, exceptions to confidentiality, and legal immunity for reporting physicians.

List of Questions for DMV Staff
Is physician reporting of medically impaired drivers mandatory or voluntary?
If it is mandatory, who needs to be reported, how long do physicians have to report, and what is the penalty for not reporting?What is the process of reporting a medically impaired driver?Are there any forms to fill out?Where should the forms or written letters be sent?
Is there an option to report drivers anonymously?Is the name of the reporting physician kept confidential?
If the reported driver asks the DMV who reported them, will DMV staff members reveal the name of the reporting physician?
If the reported driver has their drivers' license revoked and they appeal the DMV decision and the case goes to court, will the reporting physician's identity be revealed?Are there any legal protections or legal immunity for physicians who report medically impaired drivers?Who should be contacted to answer more questions about the reporting process?

Statistical Analysis
The data were analyzed using descriptive statistics.Our statistical analysis was performed on December 3 and 10, 2022, using Microsoft Excel, version 16 (Microsoft Corp).

Mandatory Reporting
Six states had mandatory reporting requirements (Table 1).Physicians in California, Delaware, Nevada, and New Jersey were required to report conditions that were characterized by lapses of consciousness, including epilepsy.In comparison, physicians in Oregon and Pennsylvania were required to report a much wider range of impairments, including poor visual acuity and visual field loss, memory loss in Alzheimer disease, and contemplation of suicide.Penalties for failure to report included $50 for each violation in New Jersey and possible conviction of a summary criminal offense in Pennsylvania.In addition to requirements to report medically impaired drivers via forms or written letters, physicians in Nevada had additional duties to educate patients about the dangers of operating a motor vehicle with their medical condition.
Nearly one-third of states (15 [30%]) deemed physician reports confidential, with the exception that drivers could learn the name of the reporting physician, request copies of the reporting form, or request their full driving record (which includes a copy of the reporting form).Most states (37 [74%]) deemed reports by physicians confidential, with the exception that reporting physicians' identities may be revealed in judicial proceedings.We identified discrepancies in website and DMV staff    These states required mandatory reporting and their legal codes only specified legal immunity for reporting conditions that were required to be reported; they did not specify legal immunity for reporting conditions that could be voluntarily reported.statements on confidentiality practices.For instance, in Wyoming, while the reporting form stated that the report is confidential, DMV staff said that they would tell the driver the name of the reporting physician if requested and if the case goes to court.

Legal Immunity
Of all 50 US states, 37 (74%) had state statutes that protected physicians from liability related to reporting medically impaired drivers (Table 2).California, Delaware, New Jersey, Oregon, and Pennsylvania provided legal immunity for reporting conditions that fall under mandatory reporting, but their legal codes did not specify legal immunity for reporting other conditions.Only 8 states' legal codes (16%) included clauses that protect physicians from liability if they do not report medically impaired drivers.

Instructions on Reporting
The eTable in Supplement ) did not provide any information or instructions regarding physician reporting; for these states, the instructions included in the eTable in Supplement 1 were deduced from telephone calls to their respective DMVs.

Discussion
In this study, we identified many differences in state policies regarding physician reporting of medically impaired drivers.We also identified the limited availability of online reporting instructions, anonymous reporting options, and legal protections for reporting physicians.
Geographically, the 6 mandatory reporting states were clustered in the Pacific West and Northeast regions.Although reporting was mandated in only 6 states (12%), mandatory reporting policies may affect a disproportionate fraction of the US population; according to the US Census Bureau, 21% of US residents lived in these states in 2022. 6We noted considerable variation in the definition of a medically impaired driver.Of the states that required mandatory reporting, two-thirds only required reporting of conditions characterized by lapses of consciousness.Although Nevada specifically requires epilepsy to be reported, other states named a variety of other conditions involving lapses of consciousness, including hypoglycemia associated with diabetes and narcolepsy.
Other states seemed to view conditions, such as vision impairment and dementia, on a continuum and encouraged monitoring for features of these conditions, such as advanced visual field loss. 7rthermore, many states emphasized that age alone is not a valid reason to report a driver.
Ophthalmologists, among other specialists, are routinely asked to evaluate patients' fitness to drive; however, education on policies and best practices surrounding medically impaired driver reporting is not a standard part of graduate medical education.][10][11][12] This lack of awareness may be explained in part by our finding that one-third of DMV websites have no information regarding physician reporting of medically impaired drivers.In addition, there is a dearth of published information on this topic.The National Highway Traffic Safety Administration may be well positioned to help state DMVs establish best practices on how to present instructions and resources regarding physician reporting of medically impaired drivers; furthermore, state legislatures hold the power to regulate these policies and provide resources to make reporting systems available.
One risk associated with reporting a medically impaired driver is potential damage to the physicianpatient relationship. 9Physicians may fear that reporting a medically impaired driver may lead patients to seek care from other clinicians, withhold information regarding their symptoms, and, potentially, retaliate against them.As such, physicians may be more inclined to report at-risk drivers if there are avenues to report drivers anonymously or there are protections in place to prevent reported drivers from learning the identity of the reporting physician.Our study showed that only 3 states permitted anonymous reporting.Several states justified the lack of anonymous reporting options by citing the importance of verifying the reporting physicians' credentials, which can help shed light on the veracity of reports and curtail reports submitted with malicious intent.State DMVs may consider developing procedures to verify reporting physicians' credentials, while omitting the identity of reporting physicians in communications with reported drivers.
Although many states deemed the reporting process confidential, many states had avenues for drivers to learn the identity of reporting physicians, which we call exceptions to confidentiality.We also identified discrepancies regarding confidentiality policies and practices when comparing DMV website information with the verbal reports of DMV staff in Wyoming.As such, it is important for clinicians to cross-reference sources when researching their state's reporting procedures.Similarly, we encourage state DMVs to ensure that website information, state statutes, and the practices of DMV staff are transparent, accurate, and consistent.
The American Medical Association and the American Academy of Neurology, among other professional organizations, recognize the importance of safeguarding physicians from liability when they report patients in good faith. 1,13A study of vision care clinicians reported that they cite liability risk for reporting and for not reporting as barriers to reporting unsafe drivers. 9At the time of this study, universal legal immunity did not exist in the US.Legal immunity for not reporting may be just as important as immunity for reporting.Our study suggests that, in 42 states, physicians who decide not to report medically impaired drivers may be vulnerable to lawsuits by third parties who are injured by the impaired driver.The legal environment surrounding physician reporting continues to evolve, and physicians may benefit from reviewing summaries of legal cases involving physicians who have reported or not reported medically impaired drivers. 14e conclusions of past research on the effectiveness of physician reporting have been mixed.6][17][18] Another often-cited concern with physician reporting is that it could result in inherently safe drivers losing their driving privileges. 15,19Physicians may consider the similarities of mandated reporting of communicable diseases with the reporting of medically impaired drivers.Both appeal to physicians' duties to protect public health and safety.The American Medical Association offers ethical guidelines to help guide physicians in making these difficult decisions. 1,2Physicians are encouraged to educate patients and their families about the risks of driving and state laws regarding licensing requirements. 1,20netheless, physicians should be reassured that physicians in the US are not directly responsible for issuing or revoking driving privileges.Rather, in many states, physician reports prompt their state DMV to conduct a driving reexamination that may then compel the DMV to reinstate, set limitations to, or suspend a patient's driving privileges. 2 In many states, the final decision is made by a medical advisory board that is staffed by physicians.A study of older drivers' opinions about driving cessation reported that most older drivers believe that physicians, rather than state DMVs or police officers, should determine license revocation. 21Such findings reinforce the important role that physicians can play in identifying medically impaired drivers and counseling their patients about safe driving. 21,22

Limitations
This study has several limitations.First, this is a cross-sectional study; we collected data in November 2022 and recognize that state laws and policies may change over time.Compared with the results of a cross-sectional study on this topic performed in 2010, our 2022 study found that the same 6 states had mandatory reporting requirements and that 37 states provided immunity for reporting physicians compared with 32 in 2010. 3Therefore, clinicians and state medical societies should try their best to stay up to date with local regulations and contact DMVs directly if they have questions or concerns.Second, we surveyed 1 DMV staff member from each state; while it is possible that surveying additional DMV staff members may have yielded different results, many DMVs only had 1

JAMA Network Open | Health Policy
Confidentiality for Physicians Who Report Medically Impaired Drivers Abbreviations: N, no; Y, yes. a

Table 1 .
Details on Mandatory Reporting Requirements in 6 US States

Table 2 .
Reporting in 50 US States-Mandatory vs Voluntary, Confidentiality, Legal Immunity

Table 2 .
Reporting in 50 US States-Mandatory vs Voluntary, Confidentiality, Legal Immunity (continued) 1 provides detailed instructions on how to report a medically impaired driver for physicians in each US state, including links to reporting forms; email, fax, or mailing directions; and telephone numbers to Medical Advisory Board or Medical Unit representatives, if available.Approximately one-third of state DMV websites (17 [34%]