Dear NAM, You Complete Us.

In March, a National Academy of Medicine commission described the architecture American healthcare needs. We agree with nearly every word — and we can tell you, from experience, exactly why they're right.

There's a paper you probably haven't read, and should.

In March 2026, a commission convened by the National Academy of Medicine — some of the most serious people in the field, the kind who built the standards the rest of the industry runs on — published a discussion paper on what healthcare's data architecture should actually be. It is the clearest account we've encountered of why healthcare software keeps failing the people who use it. Most people will never read it, because it's a commission paper and it reads like one. That's a shame, because it's right about almost everything.

We know it's right, because we spent years arriving at the same conclusions the hard way — and reading it felt less like learning something new than like hearing someone finally say out loud the thing we'd been trying to say all along.

Take the paper's central point: that healthcare built its systems the wrong way down. Product by product, each with its own idea of what a patient is, each wired to the next one by hand, no shared foundation under any of it. The authors are right, and here's why we're so sure — because we watched what the alternative costs. Every time two systems have their own version of the same patient, someone spends their afternoon reconciling them instead of caring for anyone. You cannot patch your way out of that. It's a foundation problem, and foundations can't be added later. So we never built it any other way; there was never a version of this worth building that started anywhere but the ground.

Or take their point that the record should be a product of care itself, not a document assembled afterward to justify a bill. Right again — and you feel why the first time you watch a clinician spend their evening reconstructing a day from memory, because the record was never designed to capture the work as it happened. A record built to bill can only ever tell you what was charged. We built on the belief the authors land on: that the record's job is to hold the truth of what happened, and that everything else — the bill included — is something that should follow from the truth rather than distort it.

Or their insistence that as AI enters care, it has to be accountable — observable, attributable, trustworthy — rather than bolted on as a black box. We agree so completely it's almost uncomfortable, because we reached it from the other direction: not from what's ideal, but from what a clinician can defend. Anything that touches a patient's care has to leave a record of what it did and who stood behind it, or it has no business being there. The paper calls that a principle. We treated it as a requirement from the first line of code.

We could go point by point, but the pattern is the thing. On question after question, a commission of the most credentialed people in American medicine reasoned its way to the architecture we'd already spent years building — and they have never heard of us.

That last part is what makes this worth writing about. Anyone can publish a thesis about what healthcare needs; the industry is thick with them, and most are self-serving. But when the theorists and the builders — two groups who agree on almost nothing, one writing papers while the other makes payroll — independently arrive at the same answer, from opposite ends of the earth, without either knowing the other was working on it, the answer stops being a proposal. It becomes a conclusion. You don't have to take our word for what healthcare needs. Take theirs. We just happen to be the ones who already built it.

Which leaves exactly one open question, and it's a better one than "is this the right architecture." That part's settled now. The only question left is whether someone has actually built it and can run a real health system on it. We think that's a conversation worth having — and we'd rather have it than write another paper about it.

The Mission Brief is where we work through the problems healthcare has to solve for the next fifty years, one at a time. If this is the architecture you've been trying to describe — or build — we'd like to hear from you.

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