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Six HCIT Lessons From Steve Jobs

October 10, 2011
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What do the Apple 3, NeXT Computer, and the Newton have in common?

Mark Hagland asked me if I would blog about the passing of Steve Jobs and how his genius relates to us working in HCIT. I’m both pleased and honored to do so. Here are my thoughts.

What do the Apple 3, NeXT Computer, and the Newton have in common? They were all ambitious, visionary products for their time that objectively failed, but also set the stage for subsequent, wildly successful products including the iPhone and iPad.

As we consider Steve Jobs' life, the overwhelming lesson I draw is that no matter how clear, compelling and exciting a vision may be, to succeed it requires a lot of patience, hard work, and the ability to survive failure. What made Steve Jobs so clearly effective has direct implications for HCIT. Here's my short list:

1. Have a portfolio of projects; you cannot tell which seeds will succeed and you cannot predict the weather.

We all need to show progress. To do so, we need to have enough alternatives available to effectively determine what technology works in terms of our customers’ needs and wants. The broader your portfolio, the more synergies you create. You can’t hit a homerun every time you step up to the plate, but when you do, your strikeouts are quickly forgotten.

The iPod isn’t just an “ecosystem” of a music player, a music store, an iTunes application, and a wrap-around marketing strategy. It created a halo to also sell computers that simply worked better for creative users, and attracted powerful support from and partnerships with companies such as Disney.

2. Be clear.

There is a tension between brevity and clarity, which is rarely brief! Part of the genius of Steve Jobs was in his dedication to doing the work that created clarity in the form of delivered products and services that have been perceived by consumers as brief and succinct. The words that often describe his results are elegant and well-designed. In contrast, Apple’s competitors often produced technology and support services developed using ill conceived concepts because in many instances they ignored the real needs and wants of end users. In contrast, most of the products Steve Jobs delivered were complete thoughts. How many times have we all witnessed this in HCIT?

3. Think end-to-end, and sweat the details of that end-to-end solution.

Don't compromise your design effort early on. In my experience, my Mac computers were clearly better designed to run cooler, quieter, faster, and more reliably than equivalent PCs I was also using. The differences were objectively in the Mac's favor. There was a vision and leadership difference since the raw materials and general level of talent of the workforces were comparable. This almost always requires an innovative, and possibly narcissistic, CEO, at least in times of rapid change such as what we’re seeing in healthcare.

Healthcare CEOs who understand HCIT and value quality outcomes are, as I’ve observed, always compelling leaders who sponsor and truly respect dedicated, professional people, efficient processes, and clear policies. An easy test is to look at how an organization is approaching problem lists or ICD-10. Is it a casual, tactical approach, or is it an integral part of the long-term strategy for quality care and financial health? A strategic approach to HCIT is not a luxury, it’s a necessity. This takes commitment starting with the CEO – commitment that includes time, talent, investment, and buy in from all stakeholders.

4. Don't be lazy.

We can all be lazy at times. We also all know the right thing to do. This often demands more of us, is at times initially unpopular, and not likely to be as expedient as taking shortcuts. As a concrete example, almost all of us respond more to new emails than we do to our defined priorities. This is a form of laziness, undisciplined behavior. Jobs' deliberateness was an intrinsic part of his success. It is also critical to evolving the technologies that will help to make each of our hospitals and health systems the best on the planet.

5. You cannot do it alone. Choose and invest wisely in your relationships.

Steve Jobs worked successfully for over 30 years with a wide range of very diverse and challenging people. His success can be traced back to the influence, both positive and negative, these people contributed to Apple and his other ventures. Steve Jobs was an innovator who invested in collaboration before single mindedly forging ahead with all the force he could muster. HCIT is in a very similar environment. Work done by vendors in collaboratives, using the contributions provided by cross hospital advisory boards, associations, and through regulatory and standards bodies is more important to achieving our goals than ever before.

6. Understand and serve the consumer . . . and do it sincerely.

Each of Steve Jobs' enterprises clearly invested in trying to understand the end user. The Apple retail store experience provides multiple examples of innovations designed to serve the consumer, from the Genius Bar to the liberal return and service policies, to the broad range of training opportunities, many of which are free and amply staffed.




VC from MI writes:

1. Learn from your mistakes or "failed" products, and don't be afraid to change course. Moving to Intel chips *finally* is a good example. Apple still keeps a pretty closed system (as opposed to an Open Source Android, for instance) but they still keep that balance of choosing where they control and where they open up and play nice with others. Bone-headed determination in either direction shortchanges you and your customers. I think Jobs was probably guilty of boneheaded determination, but was quicker to recover and better at learning from it.

2. Don't underestimate the cool factor in any industry. Form certainly can't take the place of function, but I'd rather be doing cool stuff than drudgery any day of the week even if I work for a large government healthcare agency. It makes it more fun to come to work and gives me more energy to do my job better. You get more and better voluntary effort on cool things.


Thank you for your comment, especially the question on the applicability of Apple's business model and practices as they might apply to the healthcare space.

What some people took from the pre-ARRA HCIT market was that the tensions between market vs government driven, and open vs closed approaches were not delivering adequately standardized solutions that were sufficiently interoperable and affordable, in a "fast enough" timeframe.

Another dimension you touched on were the heavy-handed, control policies. I'm afraid that they are not at all unique to any one vendor. The absence of such policies lead to powerful but unstable and unreliable systems, as we have seen and still see with both other vendors and open source approaches.

My favorite metaphor is that, at the end of the day, drinking water must absolutely be made safe to drink. What goes in cannot always be taken out, so upstream management is critical.

David writes:

Steve was a master at understanding what the users wanted before they did no such example in healthcare yet but there is a upcoming IOM report on HIT and Patient Safety that will focus on this area.

Mike "MDMD" from MA writes:

it seems to me that the pressing need in HCIT is not really hardware, though god knows it there is much room for improvement (think smart beds and smart rooms). the most pressing HIT problem is usable software, IMHO. so maybe we need to look at the software engineering behind facebook and google and amazon to find pertinent examples where HCIT needs to look to get started. the hardware needs to follow the software it seems to me.

Steve Jobs didn't just survive failure. He learned from it - more effectively than I've ever seen it done by anyone else. He made gold out of lemons, realizing that it's more valuable than lemonade. He turned the Lisa into the Macintosh, the Newton into the iPhone, and even the low market share of Macintosh into exclusivity. Heck, because he got thrown out of Apple, we got Pixar. He understood that the User Experience is the reason for the technology, and that the smallest details add up to that experience. Steve Jobs' vision is why the little clock icon runs backward when Time Machine is backing up your Macintosh: not because you can't do a system backup without that detail, but just because it should.

I got my first Macintosh in 1984, because it was the first computer good enough to have in my home. I've never had reason to regret setting very high standards for technology — that's what helps keep it clear what the technology is for.


Scott Finley, MD, MPH
Senior Physician Informaticist

Kevin writes:

I think this article is a good evaluation of Steve Jobs' strengths, and how they relate to HCIT. However, he had other tendencies that, while they made him a rich man and Apple a leader in market cap, were antithetical to the needs of the biomedical informatics field.

1) iTunes: First, I must confess that I have never run iTunes on a Macintosh, so I do not have personal points of comparison. My experience with iTunes is on Windows, where it suffers from a performance penalty that my mac colleagues do not appear to experience. It installs software that Apple thinks I need, even when doing so has no benefit to me.
2) Apple App Store: The method by which software can be installed on the iPad is singularly clear. You may install from Apple avenues. Apple will decide if a vendor can sell an app in the App Store. Apple will dictate the revenue stream generated by that app.
3) OS X Lion: A colleague of mine upgraded to the latest version of the operating system, and promptly lost the ability to connect to shared server resources. After some research, we found what might be a solution, but the upgrade path was too easy to strip functionality.

The unifying theme here is that Apple does not play well in the sandbox, at least from this outsider's perspective.

I am not going to argue that Apple and Jobs are somehow unique in this quest they exercised their rights to maximize their market share and gain value for their stockholders. Yet the tendency to enforce vendor lock and the opinion that the company knows what is best for you will not further our goals in HCIT of interoperability and wide acceptance of standards.

Dr. Bormel, I wholeheartedly enjoyed your examination of the strengths of Steve Jobs, and their applicability to HCIT as a whole. Could you comment, perhaps in a follow-up post, on some of the practices of Apple that might appear to benefit the company at the EXPENSE of the larger community, and where that might play out in health care informatics? My meager experiences with iTunes on Windows, App Store policies that arbitrarily restrict vendors and OS upgrades that lose functionality show a disregard for the community outside of control, hardly a trait that forwards the goals of HCIT.

Jack from VA writes:

At his 2005 Stanford commencement speech Steve jobs said in part:

"Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven't found it yet, keep looking. Don't settle."

Words probably lost on youth at 21 but in retrospect, with the addition of "continuous competence and learning" it is the story of my successful, happy life.

I started paid work at age 12 delivering the morning LA Times then saddling horses, cleaning stalls after school. I soon used a horse instead of a bicycle to deliver morning papers in my hilly California community. I quickly doubled my subscribers because I was faster with the horse. Serendipitously we had an upsurge in riding lessons at the stable. "If that shrimp, Jack, can ride like that, I can too."

Now 64 years later, as an Internist with a boutique Geriatric practice, I use an iPhone with Dragon mobile and an iPad in the exam room to show the graphics of rotator cuff injuries. They are "horse equivalents" in my practice.

Apple's simple as a pencil and reliable approach to technology that works is a standard for us in the complex practice of medicine.

The foundation of clinical medicine, personal responsibility, has not changed. The growth of capability created by information technology is transforming us from isolated craftsmen to coordinated teams of peers coordinating our efforts uniquely to fit patients as individuals.

Another Jobs quote, "I'm as proud of what we don't do as I am of what we do." is useful to consider as we constantly strive to do a better job. We need to help the patient and the community realize that their personal responsibility to stay well helps us cure them when they get sick.

Hi Joe.
The best-supported theory of technology adoption, the Technology Adoption Model, holds that technology must satisfy two needs for successful adoption:

  1. Usefulness - it must enable the user to do something she wants to do and

  2. Usability - it must require minimal training and minimal short-term memory.

Steve Jobs never quit working toward these two goals and his most successful products and services achieved them as few others have. (Of course, he added a third goal, beauty.)

The daunting challenge for health IT is to create an integrated information system that is usable and useful to each member of the patient's care team (patient, doctors, nurses, care coordinators, pharmacists, employers, etc.) and to the team as a whole. This is a challenge that will not be met by developers who lack Mr. Jobs' unremitting passion for achieving the twin goal of usability and usefulness.


BTW, this is a good place to start reading about TAM:

Venkatesh, V. (1999). "Creation of Favorable User Perceptions: Exploring the Role of Intrinsic Motivation." MIS Quarterly 23(2): 239-260.

Dr. Bormel has tapped into the nexus of what Steve Jobs has achieved and what the American healthcare IT scene is lacking at this point in time. Focus on the essential: the relationship and communication between the patient and the healthcare provider as the core of our professions and lives. HIT must become a natural part of enhancing, augmenting, and improving that core human communication rather than a distraction. The lessons of the PC vs Mac era is that passion, commitment and focus can carve a better path to achieve a goal. From my perspective in AMDIS, It has been a privilege over the last 20+ years to watch the maturation of the role of chief medical information office (CMIO) in the U.S. At this time of rapid change and stress in our country, it is imperative that we maintain the dedication to the goal that matters: the care of our fellow man.

Charles from VA writes:

I've watched his Stanford speech several times, and it really has motivated me. He was a master at presentations and the product launch meetings.

From Carla's iphone (spontaneous shot outside an Apple store in DC):

William G writes:

in my humble opinion, he was one of a rare breed of people who are able to dovetail practicality and purpose with artistry. The latter transfoming the ordinary into the extraordinary. To me he exemplifies the notion that "good enough isn't good enough". Why just have a skyscraper when you can have the Empire State buliding? Why just have a bridge when you can have the Golden Gate. He was the Frank Lloyd Wright of the digital age. A little bit geek with a healthy dash of hip.

Doug writes:

I have one burning thought about Steve Jobs and Apple, and you've touched on it in your blog post, but to really make the point clearly would take a lot of thought and some work in developing examples. What Apple/Jobs exemplified is the transparency of technology - technology that works without the user having to think about it, much less having to be an "expert" user. My common domain of clinical systems are light years away from this ideal. The market leading best EMR vendor, Epic, is technology focused, not process or results focused, so that's the industry's current paradigm. Siemens' business process management capabilities are a step in the right direction, but just a tool. Of course, it's a lot more complex to execute a care process, or even get a bill out, than it is to order music or make a phone call, but so much could be done that's not being done.

To me Steve Jobs was a compelling example of someone whose life was well lived. He had a passion for his life's work and a genius for designing products that people actually got excited about. He was a visionary who was relentless in designing products that people—non-technical consumers—want to make part of their everyday lives.

The morning after Jobs died, I listened to the radio, which played an audio clip from his 2005 speech to the graduating class of Stanford University.(video of that speech). The first was about connecting the dots: how he ped out of college, but continued to take courses he was interested in, including one about calligraphy, an idea that led to beautiful typefaces on the Mac. The second was about love and loss: how he built up a company, only to lose it, go out and start another company, and regain control of Apple. And the third story, which relates to the audio clip, was about death. Speaking of his own diagnosis of pancreatic cancer, he remarked that "Death is very likely the single best invention of life. It is life's change agent. It clears out the old and makes way for the new."

That remark made a deep impression on me, and I think typified his life outlook, which was openness to possibilities and new ways of doing things, even if it is far from clear where innovations will lead. And to me that has everything to do with what is going in healthcare IT today: making a radical break with the way things were done before, and designing products that everyone—doctors and patients—can get excited about and use. I believe that improvements in patient safety and care quality, efficiency and accountability will come about by leveraging the healthcare IT improvements taking place today.

AP from NY writes:

Joe, In honor of Steve Jobs I think I have to send some blunt comments...his passing reminds me of the lack of good design in electronic medical records and many medical software interfaces. In fact it's baffling as to why many of the electronic record companies can make so much money with such poor design! It's is only just now that we are beginning to see that some of the record companies are beginning to represent the complexity of medical information with graphical representations of the temporal relationships of patient data. We could have had good design in electronic records a decade ago...but most all of us are just busy doctors, and too busy to fight the battle of demanding high quality tools, thus we tolerate the mediocrity of these tools we use each day. Patient progress notes represented over a timeline and its relationship to interventions such as medications and treatments should be graphically represented and could be elevated to great design. Physicians need to see instantly the problem list, SOAP, patient progress and the basis for tests and therapies that make up medical decisions in a perfect interface. Medicine should have nothing less than a perfect interface.
We all know that Apple is a consumer company impacting education at all levels and consumer products, and that has never had as its core mission professional information systems. I wish that Steve Jobs had a secret blueprint for a better electronic medical record. Maybe it will surface! Maybe CEO's at the e-record companies will start to look for visionaries that want to transform the e-record the way Larry Weed transformed the paper record with SOAP and problem lists 40 years ago. I'm not holding my breath but it would sure be good if they would just start to think about great design and better ways to not only represent data but to connect the record to the tools and knowledge that makes us visualize our patient problems and the most appropriate tests and therapies.

Thank you for a great post. I already use the iPhone and the iPad as part of my healthcare delivery and anticipate more functionality with time. I think Steve Jobs lead the way by being visionary in his efforts to shape information technology so that it could be extremely user friendly. HCIT has a long way to go, but using the Jobs method offers us the highest likelihood for successful transformation of the delivery of healthcare in America.

Joe, Thanks for the terrific post.

My favorite dimension of Steve Jobs' leadership and how it relates to healthcare comes from the 1983 story of Mac development, here ( )

In order to make it clear how important a detail was (short boot up time), Steve translated importance of shaving 10 seconds off of the time to an aggregate dozens of lifetimes, given the millions of users booting up a Mac every day.

We should all take a lesson from that, and it's impact HCIT design. Little things make a huge difference.

Perhaps the biggest lesson for healthcare information technology derives from how Steve Jobs led as a CEO, and how that relates to vendor, payer, and provider organizational leadership in our industry.  There's an interesting blog by Kieran Healy that explores this issue from several critical perspectives.  Here's an excerpt and link to the original:

"Charismatic Authority

Writing in the early part of the twentieth century, Max Weber wondered why people followed the wishes and demands of others in the absence of direct coercion. He thought there were three sources of legitimate authority: charismatic, traditional, and legal-rational. The first rests on loyalty to a specific person. You follow a person because of who they are. ... "

[full post here: ]

I was very moved by the passing of Steve Jobs—not because he was a celebrity of sorts in the IT world, but rather because he was a visionary with an uncanny understanding of both consumer needs and wants, aesthetics in form and function, and usability. Apple's customer base is testament to this. For those of us in health IT, we know all too well the distinction between needs and wants, but Steve Jobs knew how to deliver the needs, and have the consumer feel like they were getting what they wanted. Steve also understood that the key to building an ever growing number of followers and end-users is simplicity. And this goes far beyond the functionality of any single product—look to the appeal and beauty of any Apple product.

Health IT certainly has its challenges. The delivery of healthcare is one of the more complex systems to understand and is even more complex to describe. Unlike industries which rely on simple checklists or those able to automate manual processes, healthcare is intricate with patients being like snowflakes—no two alike. Further, medicine is dynamic with recommendations and guidelines, treatment alternatives and technologies changing at a rapid pace.

While I am no Steve Jobs, I am confident he would encourage us to step back from the •push' to quickly adopt technologies that simply meet requirements, and instead look at the needs of its users—the providers of healthcare, and the recipients of healthcare—the patients. If our goal is to achieve a higher quality of delivered healthcare in an integrated network of portable and shared health information, we need to simplify the product and better understand the needs of providers and patients across all specialties and geographic areas. And yes, an elegant looking device with curb appeal wouldn't hurt either!

Brook from VA writes:

One of my favorite Steve Jobs quotes: "Innovation distinguishes between a leader and a follower." I love that — the ability to set yourself apart, either individually or collectively, requires the ability to innovate.

I liked your thoughtful piece on him. I've never seen such an outpouring of sentiment and reflection over the death of an executive.

Most of us never really knew him. But I'm sure that four mistakes are being made .... the role of luck, the fact that he had tons of money to risk, the contributions of others such as Wozniack and the thousands of Apple employees, and that he was able to steal big ideas from Xerox PARC, such as the mouse, Windows, etc.

Be he certainly made a major contribution to shaping the consciousness and behavior of a generation.

You've produced a very poignant blog. It would be hard for anyone to dispute your take on how Steve Jobs career can, and to a degree already has already influenced HCIT.

I think that IA and HITmaven further clarified an important point in their comments. Steve Jobs and his team at Apple really did give consumers what they wanted in a form that has proven to be easy and fun to use. To that end, calling Jobs an inventor misses the mark. Instead, as you wrote, he was an innovator at the highest level.

Getting there first with a product is not necessarily as important as delivering the best. There is no value to a technology no one cares to use. But there is great value in technology that helps ease the burden of the task at hand, and then evolves to take a greater role as time goes on.

It was important that you wrote this post in a timely manner. I hope that you're still planning to follow up on the AHIMA convention soon. For the first time in many years I was unable to attend due to a schedule conflict and I'd like to read your "Cliff's" notes and get your impressions.


Phil goes on to write:


Steve Jobs had two stated goals for Apple: make great products and be profitable—in that order. You can't reverse those and be a great company. You can't be a great company without doing both of those. How many companies in the HCIT market use these measures? Jobs drove his company to deliver beautiful answers to needs the market couldn't clearly describe for itself. Quoting myself here: "A beautiful answer refines our experience of the world. It helps us focus our attention and expand our awareness at the same time. It isn't just about seeing—looking at an aesthetic or enjoyable presentation, for example. It inspires basic improvements in our understanding that enhance our actions. It changes things." He changed things.

Dr. Joe touches on a lot of good parallels for HIT. Build the ecosystem, not just the app. Have a comprehensive vision, but do the work to figure out and build all the pieces. And expect failures along the way.

I particularly value Statement #3: think end-to-end, but sweat all the details between here and there. Too many true believers have the vision, but presume it will all happen "automagically." Too many others want the detail perfect and the vision gets lost in the detail.

And in applying the lessons learned from Mr. Jobs, one difference we need to keep constantly in mind is that in HIT — and particularly EHRs and clinical apps — there is the patient: we need to get that part of it right first time and every time. There are lives on the line, not just competitive successes and failures.

Andy from GA writes:

I'm not sure why he was so successful but I think focus as much as tenacity was important. And a willingness to cut his loses helped a lot.

William writes:

Joe, I've read all the terrific comments posted on your blog regarding the contributions of Steve Jobs and Apple.

My Grandmother passed away from pancreatic cancer a few years ago and I sincerely hope that Steve Jobs' death will promote more awareness and research funding for curing and/or better treating pancreatic cancer. (see While the world salutes his accomplishments, I'm certain his family grieves from their more "personal loss". Please encourage your readers, if they want to say "thank you" to Steve, to do so by making a contribution of time or money, to this cause.

Dr Bormel, I think you captured several important essentials in your post. Foremost is that HCIT is in a considerably more nascent place than consumer electronics. Your point, "... first we need the right technology in place to help ensure quality care and patient safety ..." is exactly right and we're all hopeful that ARRA/HITECH/MU, especially with Stage One, is exactly what's needed --- the right technologies with the right degree of standardization.

That said, I think you missed an important key to Steve Jobs' success. He and Apple were dealing with poor competitors. Apple wasn't the first to release a tablet computer. They were, however, the first deliver one that seems to really work for people. They ultimately figured out that the secret wasn't great handwriting or speech recognition in version 1.  At it wasn't a fancy or mature operating system with full backward compatibility. A similar picture can be painted for operating systems, music and video stores, and, of course, phones.  Making them better wasn't necessarily making them more.  Sometimes, it's making them less.  Less power hungry, thinner, lighter, and full functioning.

Phones are particularly interesting. While the biggest companies like IBM, Cisco, Sony, and MicroSoft were describing Unified Communication in the mid 2005 timeframe, Jobs and Apple were conceiving and building out the entire ecosystem. Their competitors clearly were not.

The lessons for healthcare IT are pretty clear, as you laid them out. There will be poor competitors, health systems that muddle through from crisis to crisis. And there are also a group of more strategic health systems that do have a portfolio of initiatives. They invest in tribal culture, communications and leadership. They're energetic and authentically putting the consumer experience into their plans. And, they've taken a few lessons from Steve Jobs already!   Adopt early and figure out how to make things work!

Don writes:

One question I have heard over decades is, "Why doesn't Company X have Apple design their software?". The question always came from frustrated clinicians trying to grapple with indecipherable EMR software someone else purchased for them. Clinicians long for decipherable software that is as easy to use as their Macs, iPads, iPods, and iPhones. This question is the highest compliment for any software company, in this case Apple, and Steve Jobs.

Jobs famously (and infamously) enforced uncluttered and beautiful software (and hardware). He often said "no" to requests for new features and functionality, and abandoned legacy technology. Jobs often knew what his customer would want before the customer knew. And most importantly, he knew exactly who his customer was the end-user, not a CXO.

This is in stark contrast to the software factories today that manufacture healthcare software built from unimaginative toolkits and ugly widgets repeated ad nauseum. The requirements for this software are generated, without constraint (especially for those with pending contracts), by putting clinicians and programmers in the same room and expecting magic. There is no magic, understandably, because neither group understands the complete package: interaction design woven into clinical workflow, beautifully designed for regular people and not engineers. Jobs understood the complete package, and had an exquisite eye for beauty.

Steve Jobs' ultimate legacy in healthcare, in my opinion, will be the complete dominance of the iPad in all medical environments for years to come. iPads will be everywhere, as will be our memory of Jobs' unique coveted gifts.

Thanks for the thoughtful blog Joe. It is clear that Steve Jobs was successful in his ability to create and deliver products aligned with his vision and principles. We could translate this experience into the healthcare space by more effectively focusing on patient-centered solutions that respect user (patient & provider) requirements, workflows and customization.

Steve from MD writes:

Joe, I enjoyed reading your comments, and Steve Jobs passing at a young age (he must be young..he was almost exactly the same age as me!) caused me to reflect on the technological advances that occurred under his leadership, and how his past experiences, successes and failures relate to the success of achieving his visions. I have not read much about Steve Jobs leadership style, other than what has been in the NY Times recently. I hope those he worked with at Apple and elsewhere will write books so that we can understand better how Apple succeeded so well in the last decade. The not yet published biography about him that he sanctioned should also add some insight.

What strikes me as odd about how Steve Jobs is being treated in the press right now is that if it is true that he was dictatorial about design decisions, and if he was as highly detail oriented as it sounds like he was, if he were a new leader in almost any American company or enterprise today, he would be strongly advised to tone down his perfectionistic, micromanaging ways so that other workers will be "empowered". He would be told that he is destined to fail if he does not make this change. So I want to hear from those who worked with him to find out what it was really like...was Steve Jobs allowed to break all of those management 101 rules because he was just so brilliant that those around him were able and even glad to put up with it (similar to being willing to work under any conditions to be able to work at the side of a sculptor like Rodin, or an architect like Wright, etc.), or was it really more of a collaboration than it seems on the surface...clearly he surrounded himself with highly talented people, but were they always executing something specifically defined by Steve, or did a lot of important design ideas come not from Steve, but from others on the team? I would think it must have been the latter, but there too, the current press makes it sound like every idea came from Steve Jobs.

It also strikes me that Steve Jobs is a great example of how people responsible for great advances are typically what I would call insider-outsiders. Steve Jobs grew up in Cupertino, at a time when he could brashly call up a Bill Hewlett and Bill Hewlett could graciously give Steve a pile of parts to work on a project, so he was geographically and mentally kind of an insider in the entrepreneurial geography of northern California at the time. On the other hand, Steve was adopted and of limited means, and he made it clear that he never felt like he belonged in corporate culture as we know it. If Steve grew up in Dearborn, and not Cupertino, would Apple exist? I don't think so. If he weren't adopted, and of mixed background, would he have taken the hard line he took with design decisions? I don't think so. I think many great advancers...Alexander Graham Bell, and on down the list, often had this quality of being enough inside to be able to see the problem, but firmly enough outside to stand their ground when others try to beat the edges out of their ideas.

With regard to how Steve Jobs passing relates to health care information management, well, I think there is no way a Steve Jobs could succeed in the culture we currently have for enterprise development of software in the healthcare setting, or at least what I know of this culture, and this may not be a bad thing. Steve's wonderful sensibility may have been more attuned to developing devices with associated software, rather than just pure software. And I think it could be argued that health care information management is a greater challenge than envisioning or building the next successful iPhone. The most important thing about Steve in relation to advancing health care IT however is exactly what you said Joe, that Steve was willing to persist through very difficult times, was able to say no a thousand times every for every one time he said yes to a particular design...he would not be deterred from excellence, and he knew when he had discovered excellence through his iterative design process. In all of modern life, anywhere that we have mediocrity we have failure to create and maintain such feedback loops, in my view.

A friend and colleague who is an informatics nurse wrote:

Steve Jobs (he is my IT idol and I'm SO mourning him!) I enjoyed reading your blog. I was always impressed with Apple's user interfaces — if you look up Usability in the dictionary, I'm sure there's a picture of an Apple computer. I think Bill Gates got his best ideas about UIs from copying Steve's examples. Perhaps it was Steve's experience with calligraphy that inspired the Usability he brought to the design of Apple devices' UIs, but wherever the inspiration came from it was pure genius — and we could use more of that in HCIT! One hardly needed any training to be a proficient user of an Apple product.

Ryun from CA writes:

The phrases from Steve Jobs that I remember most and try to live by is. I BUILD TO WHERE THE PUCK IS GOING, NOT WHERE IT HAS ALREADY BEEN.

What a loss to the world of technology.
He will really be missed.

BTW, there's a nice description from "Rob at TII (This week in iPhone)" on how Steve Jobs improved his life, without ever meeting him. October 10th edition.

Bob from MD writes:

I think what is going to happen is that because the practice of medicine is so specialized, no one EMR or EHR can serve all specialities. Having a flexible GUI is the key. I see the day when clinicians have iGoogle or similar on their desktops, with little best of breed medical applets running in a common framework. But they run in a standards based way, drawing upon common services such as patient identity management.

R.I.P. Steve Jobs. Here's what you taught me about marketing:

1) Don't be afraid to change the conversation. While his industry was busy talking about processing speed, RAM and ROM, bits and bytes, Jobs was concentrating on human interaction, navigation, the desire to do things better, faster, and in a cool way. That speaks to the appeal of many of the products he created. He changed the conversation from one about technology to one about usability. The take-away for HCIT? Focus on various stakeholders (clinical, administrative, consumer) and really listen to the meaning of what's being said...not just the words. Don't just focus on features. Target your strategic thinking and marketing towards solving people's problems, alleviating their figurative pain.

2) Don't be afraid to challenge conventions. Marketers often bump up against "but that's the way we do things around here." Keep pushing. Brilliant products and strategies come from taking a new direction...looking at things from a totally different viewpoint. In today's "I want it my way" marketplace, end users believe everything is negotiable. Price. Features. Support. Challenge rigidity. Come up with offers, benefits, and complacency-busting products that ARE your unique selling proposition.

3) Don't be afraid to make technology alluring. Remember when computers only came in gray or off-white? When the Walkman was as portable as music got? Jobs used funky shapes, color, design zen and a concentration on usability to make everything he inspired stand out from the competition. Heck, he didn't just compete, he reshaped whatever category he moved into. Marketing isn't just about the product. For Jobs, the product often created its own buzz. It's about packaging, image, brand.

4) Don't be afraid to disappoint people. If you need everyone to like you or approve of your plans 100%, you'll spend your creative capital on designed-by-committee technology or campaigns. This won't bring about big changes or reap big rewards. Some people didn't like the way Steve Jobs did business, arguing he had a territorial approach, and wasn't always nice. I tend to side with Forbes contributor Gene Marks. (Steve Jobs Was A Jerk. Good For Him at, but there was a darker side of Jobs that does bear some scrutiny (See: The reality is that great thinkers often step on people's toes. Sometimes product launches flop (can anyone say Newton?). Sometimes people get fired. (Thanks, Apple, for allowing Jobs to help create Pixar.) If you spend all your time worrying about bad outcomes, really stellar ones will never occur.

5) Don't be afraid. Period. Jobs exhibited a kind of fearlessness that allowed him to break through boundaries. To envision technology that few could have imagined. He also knew that he had pancreatic cancer. A disease that has a 4% survival rate five years after diagnosis. It didn't stop him from dreaming. He worked until a few weeks before his death. Such was his determination to keep going, that no matter how ill he may have been, many were surprised when he missed the unveiling of the iPhone 4S.

Final words from a vintage Apple commercial sum up what Jobs probably taught us all: "The ones that are crazy enough to think they can change the world are the ones who do."

Barbara Weckstein Kaplowitz is president of Big Huge Ideas --- a full-service agency that provides copywriting, marketing strategy, Web site content development and editorial assistance to publishers, trade associations, academic institutions, manufacturers, corporations, retailers and other companies of varying sizes and shapes. You can reach her at

Rich from VA writes:

Joe, you gave a great set of insights. My own more cynical thoughts are based on the idea that the interesting part of a conditional (if, then) statement comes before the comma. E.g. If we could "", then we could solve every problem in the world. Now observe that the discussion moves to how cool that would be rather than how to do it.

So, in the jobsian perspective, he thinks he should ignore what customers and his team say and is successful because of his brilliance. However, most folks are not steve jobs but some act as though they are, with negative effects. So, if you aren't steve jobs, don't act as though you are. Make sure your efforts are reality-based and seek early and regular validation.

Jim writes:

1. Simplicity and clarity of design - the iEcosystem strives to be useful without needing a lot of instruction. It doesn't let you accomplish the same task in 10 different ways just because you prefer something different. It give you one way to do it and that way is generally well thought out. Too much configuration is not a good thing. It can end up allowing you to shoot yourself in the foot. My mother-in-law can happily use her iPad with minimal tech support and what she requires, my non-tech wife can provide. My sister's Android phone is a continuing source of problems. I can usually figure it out, but it isn"t as clear or as consistent. The HIT angle is providing a logically implementation that doesn't necessarily do exactly what you think you want, but also is tested, consistent, and hopefully reduces variance.

2. Control of the whole stack helps - Apple had a huge advantage because they control the entire system. My Macs are far more bullet proof than my Windows boxes. They just work. The Windows boxes require tinkering and upkeep. If my time as free or I considered the tinkering to recreation, the "Mac tax" would be a problem. In the HIT world, that equates to a best of breed vs. Single supplier. HOPEFULLY, the work that is happening through ONC, IHE and others will ultimately make the pieces work together more seamlessly, but that still won't result in a unified UI.

3. Content matters - a lot of claimed to prefer Archos and other manufacturers to Apple's iPods. They provided more features (FM radio, larger sizes, lower price, etc.) but the didn't provide the same ability to legally acquire music in a seamless way. You could get it in various other ways, but the experience was far from seamless. For HIT, you need the whole package. Your DSS needs to be integrated with the core system. It shouldn't be an afterthought and it should give you rules and checks that you can implement.

4. You need to be watching for and take advantage of the next wave - the enterprise EMR is entering a mature market. Revenues are good, growth is continuing, but there are fewer greenfield opportunities. In the future, everything will be a replacement in the US acute market at least. Macs were stagnant. Jobs found (or stumbled upon) the iPod. The iPod growth slowed and the iPhone was developed. Now the iPad is the new solution with the iPhone continuing strong and the iPod fading. The halo effect has revived the Mac as well. HIT companies will need to look for the next wave or be satisfied with limited growth.

Tamara's contribution - he had a lot of great ideas, but he wasn't easy to work for and ultimately he drove away a lot of good talent.

I believe the integrated stack is the way to go, but that and some of the other thoughts could be seen as self-serving. Of course I wouldn't work where I do if I didn't believe in the approach and philosophy.


Sent from my iPad

Frank writes:

As we all know Mr. Jobs had many accomplishments in the world of hardware and mobile devices. He also had his share of failures. If we are to learn anything from him it must be the old cliche 'you can knock me down, but not out'. One miss-step that comes to mind but probably long forgotten, was Apple's attempt in the mid-1990's to move into the world of healthcare systems. Apple aggressively tried to move into HIT then, and created a very slick ten minute video of their vision for HIT systems (now called EMRs). After a year or two of attacking the health/medical world they packed up and left. Just like Google recently did and many bigger firms before them. The HIT market was too fragmented and too complex, and would take far more investment than they were willing to commit to be an HIT firm. When looking at the Apple video of 1995, of which I still have a copy, the vision was amazing. It touched on community health records, hand held devices, teleradiology, Clinical Decision Support, video consults, voice driven systems, and more. Most of which we have (or are just starting to have) today. One of these days I'll get that VCR tape converted to digital and post it...somewhere.

As I have seen many times in my 35 year HIT career, Jobs and Apple had great vision but greater challenges in implementation. Today the Ipad is the mobile tool of choice. They succeeded by focusing not on the application and underlying business logic, not the data base, but on the presentation layer and user device. Success comes in many forms and usually not the way we first expect.

Bill writes:

While I certainly admired the achievements, I also have some cynical observations, and expect that after all the fervor has died down, there will be a more balanced view that emerges, compared to the current secular canonization. I am not sure that Apple should be credited with being an innovation factory. Maybe a "usability" factory, or an "identity factory," but it strikes me that most of the innovations were pioneered elsewhere, and Apple figured out how to take advantage of the work of others. That's obviously not a sentiment I'm willing to discuss in public, until the religiosity of the moment has subsided.