On July 22, 2026, a transmission line fault in Ashburn, Virginia—the heart of the world’s largest data center cluster—knocked more than 3 gigawatts of load off the grid in seconds. And it wasn’t the first time. Two years earlier, a single failed surge arrester dropped roughly 60 Virginia facilities and 1,500 megawatts at once. No one could anticipate so much uniform load responding to grid faults the same way, at the same time.

The AI power debate is mostly about generation: more turbines, more solar, more transmission. The grid needs more electrons. But the outages in Virginia weren’t supply failures; they were architecture failures. And a giant wave of interconnections is arriving on that same architecture, putting grid reliability at risk. It’s a problem nobody wants to own.

Asking more from the grid

The grid was built around predictable loads: steel mills, refineries, and houses at dinnertime. Different load sizes, same process—drawing power smoothly, misbehaving occasionally, and recovering gracefully.

But AI data centers don’t behave that way.

An AI campus can swing 70% of its load in milliseconds during a training run, then trip offline just as fast at the first sign of trouble upstream to protect billions in compute. Each is rational alone. Together, at gigawatt scale, they’re a problem the grid has never solved—and the next wave of data center campuses is planned at exactly that scale.

Where the old stack breaks

The standard data center power stack hasn’t changed in decades. Medium-voltage power arrives, transformers step it down, low-voltage uninterruptible power supply (UPS) units condition it, and it reaches the racks. Push that design to AI scale, and it cracks in three places.

First, the UPS sits deep inside the building, close to the racks. But its batteries are an undersized spare tire, designed to handle an outage for a few minutes, not to absorb load swings this fast and volatile around the clock.

Second, the UPS spends most of its life in bypass. Legacy converters waste enough power that operators run in eco-mode: A static switch feeds the racks directly from the grid and nothing filters in either direction. The compute’s swings go out raw, and grid transients—sub-millisecond events that can damage or take down equipment—come in too fast for any switch to catch.

Third, the protection logic was written when “large load” meant 50 megawatts. This protection logic can’t see the grid it is now a part of, so when trouble hits upstream, it does exactly the wrong thing: it drops out. In the 2024 Virginia event, most of the lost load traced to protection schemes that count voltage dips and disconnect on the third one—as designed, at the worst moment.

This isn’t sloppy engineering. It’s careful engineering the load has outgrown.

Moving into the path

The fix is three moves, made together.

Move it up—from 480 volts to medium voltage (13.8 kilovolts and higher), the voltage large sites draw from the grid.

Move it out—from the data hall to modular enclosures near the substation so the building holds only compute and the cooling that keeps it alive.

Move it into the path—instead of a battery that watches and reacts, a system every electron runs through, all the time. There’s nothing to detect and nothing to switch because nothing was ever routed around it.

On paper, three straightforward upgrades. In practice, they rewrite every line item downstream.

Making the change

When thousands of GPUs spin up together, the system absorbs the swing and hands the grid a flat load profile. When a disturbance hits, the equipment behind it never notices. A difficult neighbor becomes a predictable one. And when the utility needs help, it becomes a useful one.

Interconnection changes, too. The utility certifies one medium-voltage box instead of untangling every transformer, UPS, chiller, pump, and switchgear lineup behind it. Engineers swap chip generations without a fresh interconnection study. Months come off the permitting timeline.

Inside the fence, UPS rooms become compute or cooling space. Density per construction dollar climbs.

And the economics flip. Equipment that runs at medium voltage, sits outside, and stores its own energy can qualify for tax credits, and earn revenue in grid programs like peak shaving and demand response. Backup power stops being insurance and starts paying for itself.

The architecture test

In early 2026, we tested a full-scale system at the National Laboratory of the Rockies, a U.S. Department of Energy facility and the only place in the Western Hemisphere that can replicate real grid faults and AI-scale load swings concurrently in the same loop.

We hit it from both directions: real AI load profiles hit the compute side at full medium voltage. Grid faults hit the utility side, including a full zero-voltage event. The compute side didn’t flinch. Neither did the grid side. It cleared the large-load voltage ride-through requirements from the Electric Reliability Council of Texas (ERCOT), the grid operator, with room to spare.

Those rules exist because operators no longer take facilities this size on faith, and more are coming. Most of the industry treats them as hurdles. A medium-voltage, inline system clears them out of the box. Compliance isn’t an added feature. It’s what the architecture does.

The new layer

Much of what looks like a grid problem in the AI buildout sits inside the fence, in equipment sized for a load that no longer exists. Move the right pieces up, out, and into the path, and a grid liability becomes a grid asset. Density goes up. Permitting time comes down. Backup power earns its keep.

The engineering works—and the next wave of AI factories is being built on it. The industry hasn’t named this layer yet. We call it the medium-voltage AI UPS. The name matters less than the choice: those factories can arrive as a strain on the grid or as strength for it. We already know how to build the second kind.    

This content was produced by ON.energy. It was not written by MIT Technology Review’s editorial staff.

The entrance of major AI companies into healthcare is a meaningful and welcome development, accelerating the technical foundation available to the industry.

Their models are increasingly capable of processing long clinical records, interpreting complex terminology, comparing documentation against evidence and generating coherent summaries from large volumes of information. For clinicians, operators, and administrative teams who spend significant time searching through fragmented data, these advances are helping reduce cognitive burden and make high-value information easier to access.

But healthcare leaders should not confuse model capability with operational capability.

Healthcare’s administrative challenges are caused by fragmented information, fragmented workflows, and fragmented accountability, not a lack of information. The industry has spent decades investing in systems that capture activity: electronic health records, billing platforms, payer portals, scheduling systems, call center platforms, and analytics applications. Each system records something important. But few were designed to reason across the full chain of decisions that determines whether patients get timely access, clinicians have the right documentation and providers are reimbursed appropriately.

This is the problem that AI must now confront.

Revenue cycle is becoming one of healthcare AI’s proving grounds

The revenue cycle is the process healthcare providers use to get paid for care — from scheduling and registration through coding, billing, payer follow-up, and payment collection.

It is unusually suited to rigorous AI deployment because it combines high transaction volume, complex reasoning, structured and unstructured data, measurable outcomes, and significant operational variation. It also sits at the intersection of financial performance, patient access, and administrative workload.

A single claim can be influenced by patient insurance information, clinical documentation, coding rules, payer-specific policies, prior authorization requirements, medical necessity criteria, and many other data sources and operational processes. A breakdown in any one of those areas can create downstream consequences weeks or months later.

This is why generic automation has often fallen short.

Traditional robotic process automation works well when workflows are stable and rules are predictable, but healthcare administration is neither. Payer requirements change. Documentation expectations evolve. Exceptions are common and often material.

Large language models improve part of the equation, extracting meaning from narrative text, summarizing records and supporting reasoning over complex documentation. But when used alone, they inherit important limitations. They may produce plausible outputs without sufficient traceability. They may lack awareness of local workflow constraints. They may miss payer-specific history or context that determines whether an action is likely to change an outcome.

Why foundation models will become necessary but insufficient

The major AI firms are solving real technical problems for healthcare.

Better context windows make it easier to process longitudinal records. Stronger reasoning improves the interpretation of complex clinical scenarios. Better multimodal capabilities may eventually help connect text, imaging, structured data, and clinical signals in more useful ways. Safer model behavior and healthcare-specific tuning will continue to improve adoption.

These capabilities will make healthcare work faster, more consistent and easier to navigate. But they will not, on their own, solve deep-rooted administrative complexity.

Much of healthcare’s operational knowledge does not live in general medical literature, coding manuals, or public payer guidance. It lives in the accumulated experience of what actually happens after decisions are made. For example:

• Why does one appeal strategy outperform another?
• Which documentation gaps are most likely to cause reimbursement delay?
• How does a specific payer respond to a particular clinical argument?

These insights are behavioral, operational, and longitudinal. They emerge from years of transactions, outcomes, exceptions, and human judgment.

As foundation models become more capable, access to baseline healthcare knowledge will become less differentiating. Most leading systems will be able to interpret ICD-10 codes, recognize medical terminology, summarize payer policies, and reason over public clinical criteria. The durable advantage will come from how organizations combine that model intelligence with proprietary operational data, structured knowledge, workflow context, and governance.

The technical shift: From automation to orchestration

Agentic orchestration turns foundation model understanding into coordinated action — intelligence that can follow work across systems, apply the right rules, adapt when something changes, and keep learning from what happens next.

A prior authorization workflow, for example, may require retrieving clinical documentation through fast healthcare interoperability resources (FHIR) APIs, mapping patient history to payer criteria, identifying missing evidence, generating a submission packet, routing exceptions to a specialist, monitoring payer response, adjusting patient care pathways, and learning from the outcome.

This type of workflow requires coordination. It also requires guardrails: regulatory requirements, privacy standards, clinical policies, coding rules, payer criteria, and organizational risk thresholds. One promising approach is hybrid architecture that combines LLMs with structured knowledge bases, symbolic logic, reinforcement learning, and deterministic validation layers.

At Ensemble, this is the design principle behind EIQ, our revenue cycle intelligence engine. EIQ brings together operational activity, clinical documentation, payer behavior, and reimbursement outcomes into a continuously learning intelligence layer that’s integrated with the hospital’s electronic health record (EHR). It supplements the system of record with a system of intelligence, designed to connect information and surface actions most likely to improve outcomes.

EIQ uses a neuro-symbolic approach that combines LLMs and custom small language models with rules-based reasoning. That architecture is built on one of the most robust datasets in healthcare, informed by more than a decade of award-winning operational performance, transaction history, payer behavior, and operator decision-making. The language models help interpret information and generate human-readable outputs. The symbolic layer represents policies, rules, payer requirements, and workflow constraints so the system can apply guardrails, make reasoning steps more traceable and recommend actions that fit the specific operational context.

What the next decade will reward

The contribution of major AI firms to healthcare will be significant. Their models will become faster, safer, more capable, and more accessible.

But the next decade of healthcare AI will be defined by integration, not model capability alone.

The organizations that create the most value will be those that connect models to governed data, operational workflows, domain expertise, human oversight, and measurable outcomes. They will understand that healthcare intelligence cannot live in a separate interface. It has to exist inside the decisions that shape access, documentation reimbursement, and patient experience.

This content was produced by Ensemble. It was not written by MIT Technology Review’s editorial staff.