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  • ACOEM Comments on FMCSA Proposed Rule to Establish National Registry of Certified Medical Examiners

    January 13, 2009

    Docket Management Facility
    U.S. Department of Transportation
    1200 New Jersey Avenue, SE
    West Building, Ground Floor, Room W12-140
    Washington, DC 20590-0001 

    Re: Docket No. FMCSA -2008-0363

    To Whom It May Concern:

    The American College of Occupational and Environmental Medicine (ACOEM) is pleased to respond to the Notice of Proposed Rule Making (NPRM) to establish and maintain a National Registry of Certified Medical Examiners (NRCME).

    ACOEM has long supported FMCSA initiatives to improve the quality of commercial driver medical examinations. We participated in the negotiated rulemaking committee in the mid-1990s  on the merger of the commercial drivers license and the medical examination and are pleased to see a final rule published in that area. Our former president, Dr. Timothy Key, in his letter of April 11, 2005, to the Chairman of the Senate Commerce Committee, expressed ACOEM’s support for three initiatives: a FMCSA Medical Review Board (MRB); a Chief Medical Examiner for the FMCSA; and a National Registry of Medical Examiners (NRCME). The first, the MRB, has already been established and has met; the second, the position of a Chief Medical Officer, we understand is in the planning stage. This NPRM addresses the third, the creation of a NRCME. ACOEM believes this regulation will lead to improved safety of the motoring public and will increasingly assure that commercial drivers of large trucks and motor coaches possess the required physical and medical abilities to operate commercial motor vehicles.

    ACOEM strongly supports the educational component of the NRCME. We have been educating health care providers for over 15 years on medical standards for commercial drivers. In addition to full day courses, regular updates and case discussion seminars, ACOEM also publishes a quarterly newsletter, CDME (Commercial Driver Medical Examiner) Review, which provides updated alerts on changes in regulations and guidance in difficult decision cases.

    ACOEM supports Alternative 3 discussed in the Regulatory Evaluation section of the NPRM which is based on the current Department of Transportation Medical Review Officer model.  ACOEM supports medical examiner training conducted by private sector providers accredited by a nationally recognized medical professional accrediting organization. This could either be conducted using a core curriculum designed by the FMCSA as in Alternative 1 or by a medical professional organization approved by FMCSA as in medical review officer (MRO) training. ACOEM would support maintaining a centralized database of all currently certified commercial driver medical examiners. This would allow both carriers to easily identify certified medical examiners in locations near where they live or work.

    Both training and certification should use current technology, with remote training and internet base testing available as alternatives to on-site courses and exams.

    ACOEM agrees with the NRPM requirement that examiners be recertified every 6 years in order to remain listed on the registry, but would suggest that ongoing training requirements be similar to MRO training, i.e., 12 hrs of advanced training every three years. With documentation of this type of training, the need for the medical examiner to repeat the entire training needed for the initial certification process every 12 years would be unnecessary.

    The 48-hour requirement to provide documentation when requested is reasonable, but the monthly submission of examinations performed is burdensome, and compliance by examiners with this requirement will be a problem. Also, a monthly submission would be inadequate to ensure that unqualified drivers are not operating, or that examiner shopping is not occurring when drivers are not satisfied with the outcome of their examination. There should be a mechanism for the examiner to transmit (e.g. within 48 hours), information on any driver who is found to not meet the FMCSA medical criteria. This would be consistent with requirements of several states which require MROs to transmit results of positive drug screens on commercial drivers.

    One area not addressed in this rulemaking is incomplete examinations. There are many situations where drivers are required by medical examiners to either obtain additional medical information (e.g., hemoglobin A1c or glucose levels in a diabetic not on insulin) or to have additional testing (e.g., a stress test). Often, these drivers will not obtain the additional information, and might seek another examiner. There should be a requirement that incomplete examination results are also entered on the log with a notation of what documentation is missing. As for disqualified drivers, examiners should be required to submit information on incomplete examinations shortly after it appears the driver will not be returning. A reasonable option would be to permit 10 business days to provide the required documentation or documentation that the required testing has been scheduled. If testing is needed, this should be completed with 10 business days as well but could be extended for an additional 10 business days if the medical examiner agrees this is reasonable. At the end of this period, the examination should be submitted as incomplete.

    In some situations, a driver is initially found to be qualified but later becomes disqualified prior to the expiration of the medical certificate. This may occur if the driver is begun on insulin, has a myocardial infarction or, upon review by a third party or corporate medical director, is found to not meet the medical criteria. There should be an option to submit information when an examiner is aware that a driver is no longer medically qualified but may not yet have undergone a new examination.

    With the merger of the CDL and medical examination processes, information on disqualified drivers should be maintained in the Commercial Driver's License Information System (CDLIS). With the recent final rule, a driver is required to provide certification status, but there is no requirement for the driver to submit the results of a disqualifying examination.

    We also question the three year record retention duration proposed, believing it is too short. For many federally mandated occupational medical examinations, the retention duration is employment plus 30 years. Federal drug testing regulations generally require negative results to be maintained for at least one year and positive results for at least five years. Most states require a health care provider to keep medical records for at least seven years. ACOEM suggests that the Medical Examination Reporting Form should be maintained by the examiner for at least six years (three two-year examination cycles). Drivers may leave and then re-enter the driver pool. Having historical examinations to review will assist in ensuring that medical conditions which are present but controlled will not be overlooked. Almost every examiner can relate situations where a driver with heart disease, hypertension or other conditions, will check the “no” box in the belief that, because their condition is controlled, it is no longer present.

    ACOEM is the pre-eminent medical organization committed to enhancing the health and productivity of workers and their families and would be willing to offer further assistance. Please contact Patrick O’Connor, ACOEM’s Director of Government Affairs, if you have additional questions or need additional information. He can be reached at 202-223-6222 or by e-mail at patoconnor@kentoconnor.com.

    Sincerely,

    Orford
    Robert R. Orford, MD
    President