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A book in progress · free to read

The Note Was Never the Point

Why clinical documentation is broken, how the paper chart still runs your EHR, and what comes after the note.

Jacob Kantrowitz, MD, PhD · Jackson Steinkamp, MD with Alex Butler, MD, MS; Abhinav Sharma, MD; and Wasif Bala, MD

Start reading Contents

Why we wrote this

Every clinician understands the pain of documentation in the electronic health record. We spend hours of every day getting data in and getting data out, and the systems we do it with contribute more to chaos than to clarity. For decades we have been promised that digital transformation would reduce the burden. Instead, most of us spend more time with the record than with the people it describes.

The easy response is to blame the software — the interfaces, the click counts, the alerts. The harder, more interesting response is to ask what lies beneath the software: the paradigms of information organization that every EHR, good or bad, has inherited without examination. That is what this book is about. Our central claim is that the clinical note itself — the static, single-author, indivisible bundle of text that has anchored medical documentation since the paper era — is at the root of many of the problems that plague the record today, and that alternatives are not only conceivable but demonstrably buildable.

We did not arrive at this view by intuition alone. Between 2019 and 2022 our group published a series of peer-reviewed studies: a viewpoint in the Journal of Medical Internet Research arguing that the chart should be a dynamic, fully collaborative workspace organized by topic rather than time; a feasibility study in JMIR Formative Research demonstrating a working EMR built without notes; and a cross-sectional analysis in JAMA Network Open of 104 million notes showing that fully half the text in a large academic health system's record was duplicated from earlier text. Alongside the research, we wrote — dozens of essays over several years, working out the argument in public. This book combines that body of writing into a single treatment: the rigorous framework and the lived clinical experience, together.

A note on candor: we are building a company on the ideas in this book. We have kept the main text product-agnostic on purpose — the ideas should stand on their own, and we say what we are building only in the afterword. We don't think the reader needs to trust us. We think the reader has lived this.

— Jake & Jackson

Contents

  1. Chapter 1 Introduction: Drowning Clinicians spend over half the workday in the EHR. The problem isn't the software — it's the note paradigm underneath it. The book's argument, chapter by chapter.
  2. Part I — Anatomy of a Relic
  3. Chapter 2 What a Note Actually Is A clinical note is a bundle of facts grouped three ways at once — by time, by clinical thread, and by responsibility. Understanding those functions is the key to evaluating alternatives.
  4. Chapter 3 The Paper Inheritance Single-user access, atomicity, unlinked copies, no version history: how the physical limits of paper became the design of the EHR — long after the limits disappeared.
  5. Chapter 4 The Standards That Froze Us Meaningful Use, HL7 C-CDA, and FHIR standardized the note without ever examining it. How regulation and interoperability standards locked a paper-era paradigm in place.
  6. Chapter 5 The Tyranny of the Template SOAP was built for the single-problem visit. Pre-templated exams fabricate certainty, note bloat buries signal, and perfect-looking notes hide the absence of clinical reasoning.
  7. Interlude Obituary: The Medical Note Born in ancient Egypt, survived by AI scribes and clinical decision support. A brief remembrance of the medical note, between the anatomy and the pathology.
  8. Part II — Information Chaos
  9. Chapter 6 The Five Pathologies Overload, underload, scatter, conflict, and erroneous information — Beasley's information chaos framework, as clinicians actually live it, from chart lore to the library organized by media type.
  10. Chapter 7 Seven Ways the Note Creates Chaos Atomic storage, uneditable documents, the timeslice/state conflict, chart-sized notes, slow updates, historical thread boundaries, and attestation-by-retyping — with the fix for each.
  11. Chapter 8 Copy-Paste Is a Symptom, Not a Sin Our JAMA Network Open study of 104 million notes found 50% of the record is duplicated text — and rising. Copy-paste is a rational bid for persistence, not a discipline problem.
  12. Chapter 9 The Work Before the Work Hunting, reconstructing, remembering: the unmeasured labor between a physician and the practice of medicine — why it's invisible, why it injures, and why it's tractable.
  13. Part III — After the Note
  14. Chapter 10 The Chart as a Collaborative Workspace A single, dynamically updating, fully collaborative workspace organized by clinical topic — with version history and attestation without redocumentation. It has been built.
  15. Chapter 11 The Problem Is the Unit Visits are administrative events; problems are the units of clinical meaning. On information persistence, what carries forward between visits, and the note as a generated byproduct.
  16. Chapter 12 Normalize the Surface, Personalize the Projection Consistency versus clinician autonomy is a layer error. Customize the projection, never the artifact — and scope personalization to readership.
  17. Chapter 13 What AI Changes, and What It Doesn't Faster note generation floods a broken library; whole-chart summarization loses texture, certainty, and signal. Where AI genuinely helps: building structure at the point of creation.
  18. Chapter 14 The Bridge, Not the Destination EHR write-back limits and double validation keep the full vision out of reach today. The pragmatic bridge — and six questions to ask any documentation vendor now.
  19. Chapter 15 Conclusion: Let the Work Be the Work The note is a design decision nobody remembers making. The alternative exists. What remains is the ecosystem work — and the will to stop mistaking the artifact for the work.
  20. Afterword Afterword: What We're Building Stream is our bridge: problem threads, structure at creation, visible deltas, tasks born from plans. What we're building, held to the book's own standards.
  21. Back matter References The research behind the book: information chaos, EHR time studies, the duplication and noteless-EMR papers, moral injury, and the problem-oriented medical record.