SEE RELATED ARTICLE , P. 383 .

Change is not only hard but also sometimes it is just plain ugly. When emergency medical services (EMS) first started to grow and provide services to patients outside the hospital setting, many physicians decried it as unsafe and pushed to have a physician aboard every ambulance. After we got tired of this bad idea, the next step was often to require that medics always call into the receiving facility’s emergency physician to receive medical direction. After we got tired of that waste of our time, we developed hospital “base stations,” where an emergency physician would oversee multiple cases, all while trying to care for patients in the emergency department (ED). Eventually, the medical community supported a model in which medical direction is provided through offline protocols, with occasional online communications. The current model of EMS continues to grow, mature, and provide value to our patients and is essential to the health care system.

Now, as centralized, hospital-based care continues to be moved into a more distributed health care system, freestanding EDs are beginning to sprout up “in the field.” This has already happened with other specialties such as surgery, radiology, and orthopedics but is fairly new for emergency medicine. The descriptive article by Schuur et al provides a glimpse of where that new model is growing and offers some insights into our future. Although there are variations both in ownership and structure from state to state, freestanding EDs are sprouting in areas of higher growth. The article notes that these choices reflect both the economic realities of reimbursement and the decision to match resources with areas of higher population growth as a predictor of increased demand. This generally follows the approach used by hospitals, health care facilities, and physician practices.

The messages in the media and even within the medical profession could not have been more different, using the article as proof that freestanding EDs were sprouting up to steal patients from hospitals and were actually dangerous because they weren’t in hospitals. An often-spouted theme was that freestanding EDs should be locating in areas of low income and disadvantaged populations, and that placing them in growing or higher-income areas was a travesty of justice. But few businesses can survive in those environments. Drive through such areas and keep count of the businesses such as Starbucks, Marriott, or even food stores such as Kroger, that choose to locate there. To survive, you must thrive.

When risk perception is examined, things that are new inspire fear and uncertainty, and we become comfortable with things that are old and known, even if they present much higher risk. That is simply how we think, so facts help us better understand the realities of risk. So what are the facts?

We all know that the current system of ED care is broken. In fact, we’ve known that for quite a long time. In 2006, the Institute of Medicine released its seminal report Hospital-Based Emergency Care: At the Breaking Point . The report described a national epidemic of crowded EDs, underscored the fragmentation of emergency care, and raised issues of access, patient safety, and quality associated with a burdened system. It called for major change.

This is not new. In 1990, the American College of Emergency Physicians Overcrowding Task Force published their results stating that Americans faced a crisis in health care and that crowding limited access to, and the quality of, emergency care. The task force suggested measures to address this critical issue.

In times of crowding, demand outweighs accessible resources. The effects of crowding are well recognized to affect patient care quality, experience, and outcomes. Crowding also affects other quality metrics such as timeliness, efficiency, and safety. Increasingly, we also understand that it affects the caregivers, too, with emergency physicians having one of the highest burnout rates of medical professionals.

Two major changes exacerbate this trend. First, the US population is both aging and more likely to have chronic diseases, requiring more complex evaluations and greater use of resources in the ED. Second, alterations in health care policy put greater focus on the ED. The Patient Protection and Affordable Care Act concentrated on better management of patients with chronic disease and on providing health insurance for the uninsured. It did not address acute disease or time-sensitive conditions. Patients increasingly have turned or are sent to the ED for treatment of their acute conditions. Even if primary care medical homes were open from 7 am to 7 pm Monday through Friday, those access points would provide availability only 36% of the time during patient demand.

How do we fix this? For decades, emergency physicians have built bigger and bigger EDs with more staff and larger waiting rooms and pleaded for others to provide services and resources that help our profession care for our patients, all while taking patients at any time of the day or night. In 2012, Kocher and Asplin noted that ED crowding was becoming a chronic disease itself and asked, “What is the crowding endgame?”

We can start by putting our patients first and leading from there. After years of asking others to help solve our problems in the ED, emergency physicians are now leading the change from centralized hospital-based EDs to a more distributed access model of emergency care that incorporates freestanding EDs. It is a model of moving emergency care to “where the patients are.”

As freestanding EDs proliferate, more information will be required. Important questions remain that, like medicine itself, can best be answered over time and after continuous adjustments. Freestanding ED, EMS, and health system data can bring better insight into the types of patients and acuity treated; system’s and facilities’ quality care performance; best approaches to time-sensitive conditions; effects of patient distribution on crowding, quality care, and safety; optimal integration with EMS and the spectrum of health care facilities; incorporation with public health and disaster preparedness; overall cost-effectiveness and total cost of care; and optimal value in care continuum. All of this is required to best integrate emergency care within a region into a meaningful whole that improves emergency care for our patients.

Emergency medicine will lead this change. The transition in emergency care is not an “us versus them” phenomenon but one in which we as emergency physicians work together to build our own future—for our patients, our communities, and our profession.