In our imagined future, emergency departments have changed significantly since 2018. Technological advances like artificial intelligence (AI), remote patient monitoring, and telemedicine have increased access to care (particularly for underserved patients); allowed for earlier detection of life-threatening illnesses; and led to more precise triaging of patients before arriving at the emergency department. This has allowed emergency departments to anticipate and prepare for most patient arrivals and for board-certified emergency physicians to perform medical screening exams remotely and schedule patients to see their primary care physician or a subspecialist if more suitable. The reimbursement landscape and the business model of emergency medicine have finally adapted to the world of value-based care, and emergency departments are actually being reimbursed for sending lower-acuity patients to primary care physicians and subspecialists.

Perhaps the biggest change has been the elimination of most inpatient general medicine beds in America. Based upon each patient’s individual pharmacogenetic profile, robots start IVs, administer medications, and draw blood work at home, then drones transport these samples to labs for analysis. Due to physicians being able to remotely monitor patients’ vital signs and clinical status, the need to admit patients has plummeted. This has resulted in the majority of America’s acute care hospitals being closed. However, the need for emergency physicians has only grown, with micro-hospitals and freestanding emergency departments popping up from coast to coast, driven by the need for every community to have access to the acute care system as well as a desire to have a highly trained diagnostician physically evaluate patients in an increasingly digitized world.

A few hours later, Mr. Smith’s clinical status starts to decline. He becomes more hypoxemic and tachypneic. The smart ultrasound wheels itself back to meet Mr. Smith in the resuscitation bay, and the AI software notices a dilated right ventricle with reduced tricuspid annular plane systolic excursion (TAPSE) consistent with a pulmonary embolism (PE). Dr. Casillas checks his advance directive through the national next-generation health information exchange prior to intubation and alerts his family members who had subscribed to his real-time care feed. The hype of medical informatics has been realized as patients’ social, wearable, clinical, and genomic data are finally integrated into electronic medical records. A few minutes later he codes, and Dr. Casillas initiates extracorporeal membrane oxygenation (ECMO) and pushes tissue plasminogen activator nanobots, which have replaced the need for intravenous thrombolytics and catheter-directed thrombolysis. Initiating ECMO on a 72-year-old had become routine since the mid-2030s, when life expectancy surpassed 100. The AI resource allocation software then notices that, given his need for dedicated PE and ECMO teams, as well as local bed availability and risk-adjusted patient outcomes data, it would be best to transfer Mr. Smith to a hospital 90 miles away, bypassing three local centers. A minute later, he is loaded into an ICU drone equipped with tele-ICU capabilities and a midlevel critical care proceduralist, and he is whisked away. Because of the efficiencies of transferring patients to the nearest open bed available with appropriate resources rather than the closest hospital or the hospital that just so happened to be connected to the emergency department, the word “boarding” has been relegated to “back in my day” stories.