Mission-critical Ajax: Making Test Ordering Easier and Faster at Quest Diagnostics David Rapperport

Diagnostics Testing: In the U.S., it is estimated that the cost of laboratory testing is only 3% of the total annual cost of health care. Yet, up to 80% of objective information used in diagnostic decision making is estimated to come from laboratory tests* * American Society for Clinical Laboratory Science Mar/Apr 1998

Diagnostics Testing:

In the U.S., it is estimated that the cost of laboratory testing is only 3% of the total annual cost of health care. Yet, up to 80% of objective information used in diagnostic decision making is estimated to come from laboratory tests*

* American Society for Clinical Laboratory Science Mar/Apr 1998

Background About Quest Diagnostics: The leading provider of diagnostic medical testing in the US Offer access to its services through its national network of laboratories and patient service centers Quest's Care360 web-based lab ordering system is relied upon by more that 100,000+ physicians throughout the US Typical application users are; Physicians, Phlebotomists, Hospital Techs, Nurses, and other Healthcare workers

About Quest Diagnostics:

The leading provider of diagnostic medical testing in the US

Offer access to its services through its national network of laboratories and patient service centers

Quest's Care360 web-based lab ordering system is relied upon by more that 100,000+ physicians throughout the US

Typical application users are; Physicians, Phlebotomists, Hospital Techs, Nurses, and other Healthcare workers

Background Quest Diagnostics’ scale 150,000,000 Patients tested each year 550,000 Patients tested each night 41,500 Employees 2,000 Patient Service centers 185 Laboratories Data from the Quest Diagnostics 2006 Annual Report

Quest Diagnostics’ scale

150,000,000 Patients tested each year

550,000 Patients tested each night

41,500 Employees

2,000 Patient Service centers

185 Laboratories

Data from the Quest Diagnostics 2006 Annual Report

Background Ordering a test is a complex task Rule based ordering (77m rules currently dynamically applied) Accurately specifying correct required data Different regulatory requirements State, National, and International Payment via Government and private payors

Ordering a test is a complex task

Rule based ordering (77m rules currently dynamically applied)

Accurately specifying correct required data

Different regulatory requirements State, National, and International

Payment via Government and private payors

Background (application) Care360 has been internet-based since May 2000 Cache and WebLink based Proven to be very stable, secure, and scalable Standard page/form mode web application Frames, complete page refreshes as user progressed through steps Some field level “Ajax” like validations db retrieval using hidden frame submissions and hand crafted JavaScript Current scale 750,000,000 HTM Six-Sigma availability over the last 5 years Code base includes 600+ Cache classes and 500+ dynamic WLD active server pages

Care360 has been internet-based since May 2000

Cache and WebLink based

Proven to be very stable, secure, and scalable

Standard page/form mode web application

Frames, complete page refreshes as user progressed through steps

Some field level “Ajax” like validations db retrieval using hidden frame submissions and hand crafted JavaScript

Current scale 750,000,000 HTM

Six-Sigma availability over the last 5 years

Code base includes 600+ Cache classes and 500+ dynamic WLD active server pages

Ordering the old way

Ordering the old way

Ordering the old way

Issues Ordering process is cumbersome when implemented as “traditional” web application Huge, complex web pages Complex tree of possible transitions between pages

Ordering process is cumbersome when implemented as “traditional” web application

Huge, complex web pages

Complex tree of possible transitions between pages

Issues Care360 should aid customers Constantly inputting many orders a day Speed and efficiency highly important This is not buying a book…. The act of placing a medically and financially correct order can never be too fast. BUT, designs must constantly balance “easy of use” versus “speed of entry”

Care360 should aid customers

Constantly inputting many orders a day

Speed and efficiency highly important

This is not buying a book….

The act of placing a medically and financially correct order can never be too fast.

BUT, designs must constantly balance “easy of use” versus “speed of entry”

Issues Difficult for team to collaborate effectively: Modifying different parts of the same pages Big, complex pages cause maintenance headaches Original author may not be maintaining it What the page does takes valuable time to discover Multiple concurrent version development Many versions under development at the same time

Difficult for team to collaborate effectively:

Modifying different parts of the same pages

Big, complex pages cause maintenance headaches

Original author may not be maintaining it

What the page does takes valuable time to discover

Multiple concurrent version development

Many versions under development at the same time

A case for Ajax? So, did Ajax warrant the hype and deliver the goods at Quest Diagnostics?

So, did Ajax warrant the hype and deliver the goods at Quest Diagnostics?

Our plan Leave the main core of Care360 alone Evolution versus Disruptive Innovation Just add/integrate not “Rip and Replace” Add a new “EZ-Order” option that applied new Ajax techniques Re-design of UI Broken down into small, atomic units “ Container page” containing designated target <div> placeholders Also modal “lightbox” pop-up <div> panels

Leave the main core of Care360 alone

Evolution versus Disruptive Innovation

Just add/integrate not “Rip and Replace”

Add a new “EZ-Order” option that applied new Ajax techniques

Re-design of UI

Broken down into small, atomic units

“ Container page” containing designated target <div> placeholders

Also modal “lightbox” pop-up <div> panels

EWD vs. ZEN Decision CMMI – Substantial Decision Analysis and Resolution Process (DAR) Completed Product Requirements: Bidirectional Session Integration with WLD Continue to use DMZ hardened and proven MGW Infrastructure Reuse of existing backend array based method returns Cache 5.0.x compatibility Fast Learning Curve for current WLD Developers Extremely aggressive business timeline requirement

CMMI – Substantial Decision Analysis and Resolution Process (DAR) Completed

Product Requirements:

Bidirectional Session Integration with WLD

Continue to use DMZ hardened and proven MGW Infrastructure

Reuse of existing backend array based method returns

Cache 5.0.x compatibility

Fast Learning Curve for current WLD Developers

Extremely aggressive business timeline requirement

Our Decision EWD was selected due to it’s ability to meet the defined requirements ZEN has many positive attributes but for this project it was not able to meet our required needs within the timeline Additional EWD Benefits Concise browser payload ~(25%) difference Contextual Multi-lingual support Adaptation Layer for 3 rd Party JavaScript Libraries Implementation; extjs, ejscharts, yui, dojo, etc. Deployable as WebLink, CSP, PHP, or JSP application

EWD was selected due to it’s ability to meet the defined requirements

ZEN has many positive attributes but for this project it was not able to meet our required needs within the timeline

Additional EWD Benefits

Concise browser payload ~(25%) difference

Contextual Multi-lingual support

Adaptation Layer for 3 rd Party JavaScript Libraries Implementation; extjs, ejscharts, yui, dojo, etc.

Deployable as WebLink, CSP, PHP, or JSP application

Technical Solution Using Enterprise Web Developer (EWD) Ajax framework Concept of page fragments Replace the innerHTML of specified target tags Compatible with Quest’s existing technical infrastructure

Using Enterprise Web Developer (EWD)

Ajax framework

Concept of page fragments

Replace the innerHTML of specified target tags

Compatible with Quest’s existing technical infrastructure

Container Page: <div> breakdown Page1 OrderDetail PatientInfo StandingOrder Patient SearchList / InfoDetail Billing InsuranceInfo GuarantorInfo Comments

Ajax Application Flow Container Page Fetch data Pre-page Script EWD State & Session Management Back-end Server Front-end technology (WebLink, PHP, CSP etc) Generate Page

Ajax Application Flow Container Page Fetch Page Fragment Page Fragment Fetch data Event Replaces DOM content Pre-page Script Pre-page Script EWD State & Session Management Back-end Server XMLHttpRequest Generate Fragment

Ajax Application Flow Container Page Fetch Page Fragment Page Fragment Fetch data Event Replaces DOM content Pre-page Script EWD State & Session Management Back-end Server

Ajax Application Flow Container Page EWD State & Session Management Back-end Server

Timescales and resources 4 developers 45 days each Tasks: Learn the technology and methodology: Advanced JavaScript, Ajax, JSON, YUI, etc EWD Toolset Deliverables: Phase 1 production ready

4 developers

45 days each

Tasks:

Learn the technology and methodology:

Advanced JavaScript, Ajax, JSON, YUI, etc

EWD Toolset

Deliverables:

Phase 1 production ready

End Product

End Product

End Product

End Product

User satisfaction User trials were fully successful Full production rollout successful Some initial performance issues that have been ironed out Due to many more, but smaller, back-end transactions

User trials were fully successful

Full production rollout successful

Some initial performance issues that have been ironed out

Due to many more, but smaller, back-end transactions

User Interface improvements Flow through the complexity of ordering is now much more intuitive The impression is that of a much slicker, more responsive interface Each event just changes a small area of screen

Flow through the complexity of ordering is now much more intuitive

The impression is that of a much slicker, more responsive interface

Each event just changes a small area of screen

User Interface improvements Not yet fully utilizing pre-emptive, asynchronous data-fetching Currently using pre-fetching in application where long option lists are expected via Dynamic Select List More potential opportunities for this in the future

Not yet fully utilizing pre-emptive, asynchronous data-fetching

Currently using pre-fetching in application where long option lists are expected via Dynamic Select List

More potential opportunities for this in the future

System/performance: pros Performance good during ordering process Good scaling with load balanced app and web servers JavaScript performance adequate

Performance good during ordering process

Good scaling with load balanced app and web servers

JavaScript performance adequate

System/performance: cons Application Servers work harder managing more, smaller, Ajax transactions Potential client issues with any JavaScript error that can stop client processing Not so good for users with latent internet connections

Application Servers work harder managing more, smaller, Ajax transactions

Potential client issues with any JavaScript error that can stop client processing

Not so good for users with latent internet connections

Security No adverse problems experienced to date Independent penetration test completed with no EZ-Order issues uncovered EWD’s Ajax framework secure in our deployment

No adverse problems experienced to date

Independent penetration test completed with no EZ-Order issues uncovered

EWD’s Ajax framework secure in our deployment

Development & Maintenance Simplified the design and construction of the UI and the user’s work-flow Allowed much better work breakdown Allowed individual functions to be assigned to individuals Each concentrated on his/her fragments Clean, well defined interfacing of fragment modules

Simplified the design and construction of the UI and the user’s work-flow

Allowed much better work breakdown

Allowed individual functions to be assigned to individuals

Each concentrated on his/her fragments

Clean, well defined interfacing of fragment modules

Development & Maintenance Already experiencing lower maintenance overhead compared with the “classic” web approach Smaller team required to support new module More reuse possible Faster for bug-fix and enhancements No one module is overly complex

Already experiencing lower maintenance overhead compared with the “classic” web approach

Smaller team required to support new module

More reuse possible

Faster for bug-fix and enhancements

No one module is overly complex

Business improvements Marketing very pleased with the product and aggressively selling Very well received at HIMMS Conference Recognized by AjaxWorld at their 2008 Conference

Marketing very pleased with the product and aggressively selling

Very well received at HIMMS Conference

Recognized by AjaxWorld at their 2008 Conference

Conclusions Ajax is not just hype Ajax really does bring business benefits

Ajax is not just hype

Ajax really does bring business benefits