We recently had an interesting exchange with neurosurgeon Ahilan Sivaganesan at Hospital For Special Surgery on this exact disconnect.  He describes it as the "Twin Sins" of healthcare: Prior authorization acting as both a barrier to high-value care and an enabler of low-value care.

The root cause isn't just policy—it's an Engineering Problem.

Most systems today are "scraping the exhaust"—attempting to find clinical meaning in billing codes and messy notes after the fact to "guess" at an outcome.  This is "schema-on-read," and it creates an inference gap that insurers use to deny innovative treatments like TOPS surgery.

To build the Learning Healthcare System Dr. Sivaganesan envisions, we need to move to Structuring at the Source.  By defining the structure before the care happens (“schema-on-capture”), we:

• Mint Ground Truth:  Physicians capture high-fidelity, longitudinal evidence as a byproduct of their workflow.
• Override Static Rulebooks: We provide deterministic proof of value that carriers can no longer ignore.
• Restore Scientific Sovereignty: The clinician—not the administrator—becomes the primary architect of the evidence.

Healthcare doesn't need more "data exhaust." It needs new rails for clinical veracity.