Category Archives: centre vs edge

Edge-driven collaboration: co-creation

by Philip Boxer

Everyone is collaborating these days.  Collaboration has come to mean any working together by some team of specialists around a common goal.  But is there something different about a collaboration that is edge-driven?  When a number of individuals come together from different organizations in order to manage the care a person receives over time, is it different from specialists collaborating within a single organization?

The answer put forward here is “yes”, because of differences in both the required approach to governance and in the nature of the object around which the collaboration takes place – edge-driven collaboration is essentially a learning process in which there is co-creation, something more than the sum of the parts emerges. For example, collaboration under terms dictated by a Health Care Trust is of a different nature to collaboration between independent care specialists coming together around the treatment of  the complex long term condition of a particular patient.

Why this answer? A two-by-two helps to explain:

  • An organization that operates with a particular business model defines its boundary in terms of the capabilities it uses over which it has direct control, and in terms of its perimeter if it includes the capabilities over which it has contractual control. For example, the perimeter of a primary care practice will include the physiotherapists and psychologists on contract to support its patients, while its boundary will only include those directly employed by the practice.
  • An organization that defines its relationship to demand in terms the variety of products and services that its business model is designed to supply takes up a symmetric relation to demand, which it will define in terms of the markets it has chosen to serve.  A ‘market’ is thus some aggregation of individual demands for its products or services, for example the market for hip replacements, defining a symmetric relation to demand.
  • If then we consider any individual patient presenting such a symmetric demand, and consider what is not satisfied for that patient by the product or service (in this example providing a hip replacement), then it defines a value deficit – something still left to be desired by the patient. For example, not included might be the way the patient subsequently uses their hip replacement as a result of the way they walk. If the supplying business was to include this value deficit as part of what it was trying to satisfy, it would make the demand asymmetric to their business model. Such an asymmetric relation to demand defines an edge.

The following puts these concepts together, with movement towards the bottom-left corner involving increased North-South dominance; and movement towards the top-right corner involving increased East-West dominance:

Within this space, a business model that ignores asymmetries of demand and brings capabilities in-house or under contractual control (the two green arrows) is able to keep control of the way it defines collaborations of value to the business.  For example, the practice might decide that it would be more efficient to treat diabetics as a separate market, setting up treatment protocols to define the collaborations managing their care pathways.

The difficulty arises because of accelerating innovation in products and services and because of patients’ conditions becoming increasingly complex, making demands increasingly singular and heterogeneous (the two red arrows). The effect is to increase the size of the top-right quadrant and make the scope of the bottom-left approach increasingly limited.

Which brings us to what is different about edge-driven collaboration.  Its governance is different because the collaboration constitutes  the business itself, ‘outside’ its supplying businesses.  And its object is different because it is defined by the (demand-side) value deficit experienced by the particular patient.

Who pays for edge-driven collaboration?  The starting position here is that the patient pays, potentially with the quality of their life when dealing with health care. Its costs are the costs of aligning all the individual suppliers’ products and services to the particular patient’s demand.  Value for the supplier can be generated by reducing these costs of alignment.

Studies have so far shown that these costs of alignment can be 30% to 50% higher than they need to be if suppliers focus on the business of edge-driven collaboration in its own right. But this means focusing on the performance of the business ecosystem rather than on the individual business.  Not easy.

Managing primary risk needs a collaborative approach to clinical leadership

by Philip Boxer

Practice-based commissioning is intended to overcome the difficulty of driving a health care reform agenda centrally through locating management of the health care ecosystem not at its center, but at its edges where the primary care system meets the individual demands of patients’ conditions. There are a number of difficulties in making this work in practice (see what makes practice-based commissioning difficult in practice?), at the heart of which is the need for a different approach to managing primary risk.

The secondary care system supplies treatments provided by medical specialists to the primary care system. It includes the services of hospitals, but also of allied health professionals such as physiotherapists and orthotists. The primary care system is the customer of the secondary care system, supplying care provided by general practitioners (GPs) directly to patients within local communities, making the patient the customer of the primary care system.

The medical specialists in the secondary care system act as consultants to the primary care physician, and may themselves draw on the services of specialist consultants in the tertiary care system for such things as neurosurgery and cancer care.  Taken all together, these different orders of care system form a health care system through which care pathways are formed for the patient, defined by the sequence of interactions the patient has with the health care system in the treatment of their condition. Can this pathway ultimately be the responsibility of the patient’s GP alone, as the gatekeeper to the health care system?

Change in the governance of the health care ecosystem

The health care system is itself a business ecosystem, being made up of large numbers of operationally and managerially independent organizations that have to be able to collaborate with each other in varying ways depending on the nature of the pathway the patient needs to take through this health care ecosystem.  This need for horizontal forms of collaboration across the ecosystem is true even where its funding is provided centrally by the government: the ecosystem cannot be managed top-down as a planned economy. Nevertheless, health care reform by the UK Government has aimed to achieve some combination of reducing the costs of health care, increasing the quality of patient care, increasing the accessibility of possible treatments within the ecosystem, and broadening the availability of health care itself to a population.

But as discussed in the difficulties in implementing practice-based commissioning, innovation within the health care ecosystem has continued to increase the variety of possible treatments available, increasing the variety of patients’ conditions demanding treatment, and therefore the variety of (horizontal) pathways needed.  If the agility of the health care ecosystem is defined by the variety of patient pathways that it can support (i.e. type III agility in organizations), then as the demand for agility within the health care ecosystem increases, so top-down approaches become ever less effective as they are overwhelmed by the variety of patients’ demands on them. This is the driver for moving from N-S dominant to E-W dominant forms of organization, with the history of reforms to the NHS reflecting this in the way changes to the governance of the ecosystem have made the Easterly role of the primary care physician ever more important to the way the ecosystem is aligned to the needs of the patient (the stages in this evolution can be described using patterns of evolving enterprise architecture).   So given the difficulties in implementing practice-based commissioning, what more does the GP need to become effective in his or her East-West role?

The need for a different approach to leadership

The faustian pact made with clinicians by the top-down driven PCTs left the clinicians free enough to do what they could for their patients as long as they generated the aggregate results wanted by the PCTs.  The problem with this faustian pact, however, was that it prevented the health care system from learning about how clinicians were to manage the care pathways that went beyond the scope of individual clinicians or practices.  Thus abolishing the PCTs may have been necessary, but it will not be sufficient for practices to go wholly East-West dominant, since the clinicians will need new forms of support if they are to be effective in how they manage these more complex pathways in the through-life interests of their patients’ conditions.  At the same time, the Government (or in the US the insurance companies) will not allow money to be used in this way unless they can hold clinicians accountable for the way they use their know-how to manage these pathways in the through-life interests of their patients. It has the danger of becoming a stand-off, with the clinicians simultaneously agreeing with the changes while needing to buy themselves time while they work out how to manage in this new environment!

Which brings us back to the ways in which clinicians are enabled to manage primary risk. In order to be effective, their leadership has to become systemic, able to bring together the different roles needing to work collaboratively in the interests of the through life management of the patient’s condition. Such an approach depends on the availability of systems of engagement that can support collaborative working around the patient’s condition.  But more than that, it needs a collaborative approach to leadership that does not seek to place the burden of responsibility on the GP’s shoulders alone:  it needs an asymmetric approach to leadership.

What makes practice-based commissioning difficult in practice?

by Philip Boxer

The UK Government wants practice-based commissioning in order to sustain an effective focus on the increasingly chronic conditions of an aging population – in a way that can hold clinicians accountable (see the Executive Summary in Practice-based commissioning: budget guidance for 2010/11. But why has it proved so hard to make happen in practice: Practice based commissioning: what future?)? And why do doctors appear to be resisting the pace of the latest changes (UK national Health Service reforms mobilise doctors)?

What’s the problem?

“To Err is Human”, in considering how to build a safer health care system, identifies three types of error[1]: type I errors of execution in the way some particular treatment is administered; type II errors of planning in the way treatments are combined to treat a particular patient’s condition; and type III errors of intention in understanding what the particular patient’s condition really is. The first two of these are used to argue for securing the better operation of health care systems and for evidence-based approaches to defining patient pathways through them. But however well these two are managed, the quality of health care ultimately rests on the way treatments are aligned to the patient’s actual condition. Practice-based commissioning aims to improve the quality of care in general practice by enabling the responsibility for this quality to rest as close as possible to the patient within the GP consortium.

In meeting the challenge of Health Care Reform, Tom Flynn and I identified three corresponding kinds of benefit delivering step-change improvements across the UK’s NHS (a version of these relating to business is in the three agilities). These benefits came from minimising the scope for the health care system to make each type of error:

  • Type I Benefits – defining current demand for treatment and realigning care pathways to deliver them more effectively.
  • Type II Benefits – re-organising referral protocols and the configuration of clinics to improve patient pathways with respect to particular conditions within existing demand catchments defined by the Primary Care Trusts (PCTs).
  • Type III Benefits – extending the organisation of the clinical service to include re-organisation of the way patients’ demands were themselves defined by focusing on the through-life management of patients’ chronic conditions.

The orthotics pathfinders, carried out for the Purchasing and Supplies Agency of the NHS, were used successfully to test this approach in practice (for example as reported to the Scottish Parliament). They established that the scale of Type II benefits were significantly greater than Type I benefits because of the role that could be played by the orthotics clinic within the larger Primary, Acute and Long Term Care contexts. It was expected that this would be even more true for Type III benefits, but the Type III benefits could not be achieved until alignment to patients’ needs could be addressed within the larger NHS system, including collaborating with community-based services.

Practice-based commissioning was intended to deliver this alignment, with the map of medicine pathways going a long way towards defining how these Type III benefits might be achieved for patients. So why the continuing difficulty? The answer would appear to be partly structural differences between the way PCTs and GPs’ practices defined value; and partly a lack of the appropriate forms of support for sustaining the through-life focus on patients’ conditions needed by the clinicians.

Using the wrong model of value

In their 2006 book on Re-Defining Health Care speaking primarily of the US health care system, Porter and Teisberg argued the following:

“Health care is on a collision course with patient needs and economic reality. In today’s dysfunctional health care competition, players strive not to create value for patients but to capture more revenue, shift costs, and restrict services. To reform health care, we must reform the nature of competition itself.”

Central to this reform was value-based competition, something Porter enlarges on in his more recent challenge to outdated approaches to value creation and their failure to create shared value. Creating shared value means focusing on creating value in the life of the patient as well as for the provider – in terms of the above, creating Type III benefit. This argues that the continuing difficulty is because the implementation of the reforms is using the wrong model of value: managing the direct value created by providers rather than managing the indirect value created for for patients (creating value in ecosystems enlarges on the tension between these two kinds of value).

The ‘model of value’ means here the whole way in which the health care system is enabled to deliver health care, with the shift towards a primary focus on creating shared value representing a shift from a supply-side focus on markets for treatments to a demand-side focus on delivering value to individual patients.

Not supporting clinical leadership

The lessons from developing effective joint commissioning showed the importance of being able to align managed care in community and hospital settings to the through-life management of the patient’s condition within the context of their day-to-day life. This joint approach is fundamental to the practices of Kaiser Permanente, with the role of clinical leadership central to successfully transforming health care. These lessons are repeated by the early lessons in implementing practice based commissioning, showing the importance of a number of different things needing to come together: strategy, clinical engagement, managing the finances, information, and supporting practices and governance.

Current evidence on the implementation of GP consortia suggest, however, that the emphasis is still much more on migrating the top-down funding away from the PCTs to the GPs, than it is on how the GP consortia themselves need to manage health care expenditures in a different way. But in order to secure type III benefits, East-West dominance is necessary in the way GP consortia are run, in turn requiring four things:

  • Central leadership that understands the need to delegate authority to the practices where the patient’s needs are defined (i.e. asymmetric leadership), including the need for balance between these four things;
  • Practices that can focus on the through-life needs of their patients’ conditions (i.e. strategy-at-the-edge);
  • Agile health care infrastructures capable of being aligned to the particular needs of individual patients (i.e. agile infrastructures); and
  • Data platforms enabling practices to generate the multi-sided information they need if they are to be held accountable for the through-life performance of their patients’ health care (i.e. making it in GPs’ interests to be held accountable in this way).

A top-down focus enables clear progress to be made on the first two of these, while limiting the third to the forms of agility supporting Type II benefits (e.g. 18 week patient pathways). But a top-down focus prevents the fourth movement from vertical to horizontal forms of accountability (e.g. GP consortia could inherit PCT debt). This is perhaps why the GPs appear to be resisting the pace of the latest changes.

What is difficult in practice

So what might be proving difficult about practice-based commissioning in practice? The delay in giving primary focus to supporting clinical leadership probably reflects an uncertainty over whether or not it is really necessary to make the change to the axis of accountability as implied by practice-based commissioning, from top-down (vertical) to edge-driven (horizontal) accountability.

If so, it will result from the difficulty in grasping Porter’s and Teisberg’s “economic reality”: that the primary emphasis of the health care system must move from the top-down control of treatments to supporting systems of engagement with patients’ conditions that can enable GP consortia to be held accountable for creating indirect value: value in the life of their patients.

Notes
[1] These are described in greater detail in ‘Unintentional’ errors and unconscious valencies

Integrating differentiated behaviors

by Philip Boxer
Lawrence and Lorsch (1969) originated the framework of differentiation and integration for describing the agency of an enterprise. Their argument was that there had to be congruence between the forms of differentiation of behavior necessary for an enterprise to be viable, and the forms of integration of those differentiated behaviors needed for the enterprise to be able to sustain its identity. The level of differentiation of behavior at which there had to be congruence was itself determined by Ashby’s Law of Requisite Variety (1956), which stated that the variety of behaviors of which the enterprise needed to be capable had to be at least as great as the variety of demands it needed to be able to respond to in its environment.

In distinguishing levels of differentiated behavior, Emery and Trist (1965) identified four forms of ‘causal texture’ in the way demands were experienced by the enterprise in its environment:

  • Placid randomised, in which opportunities and threats were relatively unchanging in themselves, and randomly distributed throughout the environment. In this environment, which approximates to perfect competition, behaviour simply had to be operationally effective.
  • Placid clustered, in which the opportunities and threats were not randomly distributed, but clustered together in some way. In this environment, which is more like ‘imperfect’ competition, specialist forms of behaviour had to be available to address the different kinds of cluster.
  • Disturbed-reactive, in which there was more than one enterprise of the same kind in the competitive environment of the enterprise. This competitive environment approximated to the economist’s oligopoly. Each enterprise did not simply have to take account of the other when they met at random, but had also to consider that what it knew could also be known by the other enterprises. As a result, the behaviour of the enterprise had to be ‘positional’ in the sense of focused on being able to sustain positions it took up in the environment competitively.
  • Turbulent fields, in which dynamic processes arose within the environment itself which created significant variation for the enterprise to respond to – the environment was ‘alive’. In this environment, which was like a dynamic ecosystem, the behaviour had to be ‘relational’ in the sense that it had to be dynamically responsive to the particular way demands arose within its environment at any moment in time.

What distinguished this progression in behaviors was that they had to become increasingly differentiated if the enterprise was to remain viable. What particularly distinguished the fourth from the other three was that with turbulence, the ‘environment’ had to be related to by the enterprise as if it had a life of its own. This contrasted with the other three, in which the enterprise can treat the environment as if it was passive or reactive.
Whereas it is possible to argue that human service organizations in the public sector ought to treat the environment as if it had a life of its own, it does not follow that they actually do. In contrast, many ‘private sector’ businesses are having to learn how to organize relational behavior as a matter of competitive necessity even when they would prefer not to have to.

Asymmetric Leadership

by Philip Boxer

We have been used to speaking about asymmetry in the context of asymmetric demand and asymmetric governance etc in the blog on asymmetric design. These concepts and practices are being pursued through my work with the Software Engineering Institute at Carnegie Mellon University.

But what of the work associated with Carole Eigen on questions of role and leadership? For me this belongs with another kind of question associated with how leadership is to be understood within the context of an enterprise. So this blog is intended to be a place where I can follow this question. So here goes!

And just for starters, what’s with this idea of asymmetric leadership?

The idea of asymmetry has been used so far to speak of that about the other which remains not known – unfamiliar. So to work with asymmetric demand is to accept a limitation to what the enterprise knows which may challenge the very idea the enterprise has of itself. What we are doing here is starting from the Lacanian understanding of the divided subject – a person’s relationship to themselves in what they really want is by definition asymmetric to themselves. Put another way, however much I might want to know about me – about my wants, needs etc, there will always be something of myself that remains beyond my knowing – that remains personally asymmetric.

So what? Well, it creates a particular challenge for leadership, because the leader is placed between two kinds of asymmetry, in which the identity of the enterprise is constantly emerging out of these two kinds of relation: the first is the leader’s relation to their own identity as having been ‘chosen’ by the enterprise, i.e. personal asymmetry; while the second is the enterprise’s relation to the identity of its customers/patients etc., i.e. demand asymmetry.

The usual way of approaching the challenge of leadership is to express it in terms of the needs of the people working for the the enterprise. But what we want to do here is to extend this, so that the question of the leader’s relation to his or her own identity precedes the question of what identity needs to be realised through the behaviors of the enterprise.

This situates leadership with a challenge: in meeting the needs of the client-customer as ‘other’ (i.e. meeting asymmetric demands), to what extent must leadership go beyond what it knows of itself (i.e. addressing personal asymmetry)? And through what forms of authority is this to become possible and sustainable?

These are the questions that we want to follow here.

Questions about edge work

by Philip Boxer

The following questions were asked by Larry Hirschhorn about the blog on empowering the edge role, following which are my responses:

Larry: You say that edge work is breaking out almost everywhere. Can you give me an example?

Philip: We worked recently with the members of a clinic providing through-life care to patients with chronic conditions. The hospital managed the clinic’s activities in terms of treatment episodes, and budgeted the clinic according to their annual episode throughput. Because patients stayed with them long term, their budget tended to keep increasing because more patients were referred to them than died or left the area. But their budget couldn’t keep increasing. So instead patient care was rationed, the result being systematic under-use of the treatments available, to the long term detriment of the patients.

Larry: Where does ‘edge’ come into that?

Philip: As part of an acute care system, it made sense to treat the clinic as part of the centralised drive to provide cheap treatments. In these terms, the patients had to fit in with the hospital’s programming to provide the most efficient use of its resources. But the conditions in the clinic needed to be treated on a through-life basis, each course of treatment being designed to fit the particular patient’s condition. This meant the clinic’s (and behind that the hospital’s) resources fitting in with the programming of the patient’s treatment.

Larry: What made the project challenging?

Philip: First of all, although the clinicians had high situational awareness of their patients’ conditions, their ability to synchronise the behaviour of their own and others’ clinics around the needs of the patient were very constrained by the hospital’s internal processes of referral. Secondly, there was no way of holding the clinicians accountable for the way they aligned treatments (and costs) to patients’ conditions. Thirdly, the senior management used fixed budgets as a way of controlling the aggregate performance of clinics, there being no way of flexing them according to the mix of conditions different clinics were being asked to treat.

Larry: And how do you relate these challenges to the failings of bureaucracy?

Philip: Bureaucracy works by taking a big problem and breaking it down into little problems. The assumption is that if you solve all the little problems, the big problem will be solved too. This is called ‘deconfliction’ – each little problem is defined in such a way that it can be solved independently of the other problems. So the clinics with their associated budgets were defined on this basis, and as long as the levels of demand were stable and there had been enough time for patterns of treatment to settle down, things could work okay. This might have been true when both treatments and conditions were simpler, and the medicine less advanced. But it is not true now. The increasingly chronic nature of conditions, combined with the need for treatments aligned to the particular patient, means that treatments have to be adapted to patients and not vice versa. Bureaucracy can’t cope with this.

Larry: So what did you have to do differently?

Philip: There were a number of things. Firstly, we had to alter the way clinicians made referrals to each other so that authority to determine treatments was delegated as close as possible to the edge. Then we had to support the way the clinicians needed to manage treatments in a way that could also hold them accountable for the performance of those treatments. Thirdly, we had to change the way budgets were allocated so that they were based on the mix of patient conditions being treated. And finally, we had to secure funding on the basis of the cumulative cost of securing long term patient health outcomes instead of on the basis of the short term incidence of acute conditions.

Larry: Were you successful?

Philip: We proved that it was much cheaper in the long run to organise the clinic in this way in 6 different hospitals. But to sustain the changes it meant reallocating budgets on a different ‘edge’ logic across clinics. This the larger systems weren’t ready to do.

Larry: Would you say that it created more effective government due to edge work?

Philip: More effective government requires three things: the political will to do things differently, the ability to create value at the point of contact with the citizen/patient, and infrastructures sufficiently agile to make change practicable. We failed on the third count. Our brief was to make the edge work better, not to change the agility of the infrastructure. And I think that is the particular difficulty. To make the edge work better, you have to change the agility of the infrastructure, and the vested interests of the former are very different to those of the latter.

Taking power to the edge by empowering the edge role

by Philip Boxer

Preliminaries
An edge role is on a task boundary in which the systems of meaning on either side of the boundary are different: some form of translation is required. The task facing a multi-disciplinary team is often such that its members are in edge roles with respect to the areas of specialism they represent. In such a team what is being but into question across any given edge is the identity of the specialism. The challenge for the individual in this situation can be expressed in terms of taking up such a role within the life of the enterprise. The normal assumption is that, if only the nature of the task itself was sufficiently deeply understood, then ways could be found to reach an accommodation between the differing systems of meaning in the interests of the task as a whole. This is, for me, the implication of identifying the problematics of the ‘mid-game’ with those facing the edge role.

But when the team is the enterprise itself, even if such an accommodation can be found between its members, there is a further challenge: the challenge of the particular nature of the demand being presented by the client. Now the team as a whole is on an edge between the system of meaning implicit in the way they work together, and the system of meaning required to satisfy the demand. So the experts may agree how to treat the patient, but the patient may not survive the long term effects of the treatment – the patient needs to play a different game to the one the experts want to play.

The relationship to demand
edge2
Two dimensions are proposed:

  • the first describing the form of the synchronisation of task activities needed to deliver the effect required by the demand. Here the distinction is between the ‘logic’ in terms of which the form of this synchronisation is defined. High situational awareness is needed if the form of synchronisation depends on the nature of the demand.
  • The second dimension is the dynamic relationship required between the timing and logistics of what is done and the demand situation itself. Here the distinction is between whether or not the two are coupled. With coupling comes the need to manage the synchronisation with the situation itself.

So we get the four characterizations of bureaucrat, intelligence analyst, SWAT team and edge worker. But what happens when we look at the way the enterprise is able to sustain such different forms of relationship to demand?

The double diamond
diamond6
The diamond above, describing the relationship to demand, is the right hand diamond in this diagram. The left-hand diamond describes the way the enterprise sustains relationships to demand. Thus the two diamonds are symmetrical around the central vertical axis, and if some intervention creates a lack of symmetry between the positions on the left and right, then there will need to be some form of process of adjustment to bring them back into alignment. What is on the left side?

The alignment of the infrastructures
edge1

  • The first corresponding dimension is the form of responsibility given to the individual for how task activities can be synchronised. The distinction is between doing this through a span-of-control – essentially vertical relationships; or through a span-of-complexity – horizontal relationships. The span-of-control has built into it the means that imply the end, while span-of-complexity has to build means from assumptions about the end.
  • The second dimension is the form of accountability through which those responsible are held to account for the performance of the enterprise in relation to the demand. Here the distinction is between accountability in relation to hierarchy or to situation. From the point of view of hierarchy, means-ends relationships created under its aegis will by definition be transparent (regardless of what others might say were their appropriateness), while those created in response to situation will not be (because they cut across the boundaries defined by the hierarchy, and require horizontal forms of transparency).

So we get the same placing of bureaucrat, intelligence analyst, SWAT team and edge worker. And we can read ‘football player’ for SWAT team. But what about the positioning of the counter-insurgency player and of the chess player?

Who are we trying to talk to?
The chess player I have argued really belongs in the intelligence analyst position because of the underlying bounded nature of the problem space. But need the counter-insurgency position be in the intelligence analyst position?

If we contrast a ‘hearts-and-minds’ (HM) approach to counter-insurgency with a ‘helicopter gunship’ (HG) approach, then the HM counter-insurgency player will be in the edge role position, but the HG approach uses intelligence to find out where the baddies are, and then sends a SWAT force out to zap them… so what would bring someone employing the HG approach to take on the HM problematics facing the edge worker? The answer has to be based on its effectiveness in response to asymmetric forms of threat, although behind that answer there is clearly an issue of how power is used – an ethical issue associated with the long-term effects of using overwhelming force.

Ironically, the architect might be a better metaphor for the edge role position, because the form of the structure being asked for is much more arbitrary, and the challenges of aligning the available infrastructures in creating a satisfying response to the demand very evident. The architect faces the challenge of enabling the enterprise to take up a role in the life of the individual demand.

The elevator conversation
There was an article in the FT today about a study by Gartner surveying 1,400 CIOs:

CIOs had noted a shift from back-office functions towards front-office projects such as improving customer data management, looking to help the business stand out with strategic and innovative use of information, business processes, and intelligence in products and services.

To enable the business to stand out in this way is to enable it to take up edge roles… every business has to work out how to face this challenge in their own particular way.