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This paper starts a review of the state of the art in structural health monitoring with piezoelectric wafer active sensors and follows with highlighting the limitations of the current approaches which are predominantly experimental. Subsequently, the paper examines the needs for developing a predictive modeling methodology that would allow to perform extensive parameter studies to determine the sensing method’s sensitivity to damage and insensitivity to confounding factors such as environmental changes, vibrations, and structural manufacturing variability. The thesis is made that such a predictive methodology should be multi-scale and multi-domain, thus encompassing the modeling of structure, sensors, electronics, and power management. A few examples of preliminary work on such a structural sensing predictive methodology are given. The paper ends with conclusions and suggestions for further work