Development of an Online Sleep Diary for Physician and Patient Use

Abstract

This paper describes the development of an electronic sleep diary and outlines its advantages over the traditional paper based approach still used by many sleep centres throughout the world. A sleep diary is a record of sleep details filled in by a patient normally over a period of two weeks. This information is then used by a physician as a diagnostic tool for identify sleep disorders in the patient. The development method used was convergent interviews with sleep specialists in order to establish initial requirements. This was followed by a rapid prototyping approach in order to produce the final specification. This paper concludes that an online sleep diary is a low cost, viable alternative offering benefits to both patients and physicians. The benefits to patients include the ability to perform functional analysis of their own sleep habits (referred to as sleep hygiene) and to determine factors affecting their sleep patterns. This knowledge leads to greater patient understanding of their circumstances and can lead to a potential increase in patient, physician collaboration. The physician gains access to timely accessible patient information as well as to an evidence database that will allow for greater analysis of sleep disorders throughout the general public over time.

Full text

188 Knowledge Management & E-Learning: An International Journal, Vol.2, No.2.
Development of an Online Sleep Diary for Physician and
Patient Use
Jacqueline Blake*
University of the Sunshine Coast
Sippy Downs Drive, Maroochydore, Queensland 4558, Australia
E-mail: jnb006@student.usc.edu.au
*Corresponding author
Don Kerr
University of the Sunshine Coast
Sippy Downs Drive, Maroochydore, Queensland 4558, Australia
E-mail: dkerr@usc.edu.au
Abstract: This paper describes the development of an electronic sleep diary
and outlines its advantages over the traditional paper based approach still used
by many sleep centres throughout the world. A sleep diary is a record of sleep
details filled in by a patient normally over a period of two weeks. This
information is then used by a physician as a diagnostic tool for identify sleep
disorders in the patient. The development method used was convergent
interviews with sleep specialists in order to establish initial requirements. This
was followed by a rapid prototyping approach in order to produce the final
specification. This paper concludes that an online sleep diary is a low cost,
viable alternative offering benefits to both patients and physicians. The
benefits to patients include the ability to perform functional analysis of their
own sleep habits (referred to as sleep hygiene) and to determine factors
affecting their sleep patterns. This knowledge leads to greater patient
understanding of their circumstances and can lead to a potential increase in
patient, physician collaboration. The physician gains access to timely
accessible patient information as well as to an evidence database that will allow
for greater analysis of sleep disorders throughout the general public over time.
Keywords: Sleep Disorder, Online, Sleep Hygiene, Sleep Diary.
Biographical notes: Jacqueline Blake received a bachelor’s and Master’s
degree from University of Southern Queensland. Her research interests include
e-health, semantic web and supply chains.
Don Kerr is an Associate Professor of Informatics at the University of the
Sunshine Coast. He received his PhD based on the development and evaluation
of a knowledge based decision support system from Griffith University,
Australia.

Knowledge Management & E-Learning: An International Journal, Vol.2, No.2. 189
1. Introduction
A physician typically receives information on a patient from a number of sources. These
sources may be from a referral, previous medical history, test results, or from the patient
themselves. The physician makes a decision for patient care after weighing the evidence
and applying their training and knowledge to the problem. This projects aims to improve
the timing of a major source of information used to diagnose sleep disorders; namely the
patient’s sleep diary, by developing an online sleep diary. Sleep diaries are a primary aid
in the diagnosis of sleep disorders as sleep patterns impact on the symptoms a patient
displays.
Sleep disorders have traditionally been under diagnosed by a primary physician,
with only those patients who are very symptomatic being referred to sleep specialists
(Bailes, et al., 2008). There has been increased awareness of sleep disorders among
physician’s and the wider community imposing an increased burden of disease on the
current health system. This has led to a shortage of sleep specialists (Australian Medical
Workforce Advisory Committee, 2000; Patlak, 2005). The burden of disease has led to
interest in the sleep community to changing the traditional model of care for sleep
disorders to one that leverages information systems to provide efficiencies and timely
communication flows (Colten & Alterogt, 2006). Abidi (2001, p. 6) refers to the strategic
use of knowledge derived from healthcare data as being “… pertinent towards the
improvement of the operational efficiency of the said healthcare enterprise”. Hirakis &
Karakounos (2006) state that knowledge management in healthcare allows the
development of best practice models and encourages innovation through development of
the resultant knowledge base.
2. Sleep Diary
A sleep diary is used to record sleep patterns usually for fourteen nights. The person
notes the details of their nights sleep day-by-day building up a picture of sleep habits
known as sleep hygiene. Poor sleep hygiene, or insufficient time made available for
sleep may be a cause of excessive daytime sleepiness, the main symptom of a sleep
disorder. Therefore a sleep diary can be used to identify a cause for daytime sleepiness,
lifestyle reasons or a sleep disorder. Sleep diaries are used by a number of health
professionals, including psychologists, physicians and sleep specialists and is the primary
diagnostic tool for identifying insomnia. It is a very useful aid to the diagnosis of other
sleep disorders, as relatively short periods of time taken to fall asleep or frequent
awakenings are indicators of poor quality sleep and sleep disorders.
During an exploratory interview early in a project to review sleep diagnosis, the
remark was made by a director of a large public health clinic that “… sleep diaries were a
good tool which were not being used efficiently due to the timing and the short length of
time available in the consultation to extract information from the data” (J Douglas 2009,
pers. Comm. 23 Sept.). The current format of the sleep diary used in the sleep
investigation unit under study is a pen and paper questionnaire in which the patient colour
in a square between two times, for example nine and ten o’clock, to indicate bed time and
waking up time. This creates a situation where the sleep physician must clarify what time
the patient actually meant to mark. The data contained in the completed sleep diary
requires manual calculation to extract daily entries, aggregate the data and calculate the
required sleep statistics and is in a format that is difficult to quickly assimilate within a
time limited consultation. Due to the low utility of this current model of use the

190 Blake, J., & Kerr, D.
physician has difficulty in using a sleep diary effectively. The information in the sleep
diary is also in a format in which a patient can not extract information without physician
assistance.
Patient access to the information contained in an online sleep diary means the
patient gains increased self knowledge of their sleep hygiene, which has been shown to
improve health outcomes (Smith, Lang, Sullivan, & Warren, 2004). Patients will be able
to self monitor their sleep patterns. Wilde and Garvin (2007, p. 343) define self
monitoring as “awareness of symptoms or bodily sensations that is enhanced by periodic
measurements recordings and observations to provide information for improved self-
management”. Self monitoring of sleep patterns means that the patients have an
opportunity for shared decision making with their physician on the management of their
sleep disorder. Shared decision making is a significant factor in compliance with
treatment plans (Sheppard, et al., 2009). This is important in a chronic condition such as a
sleep disorder which has an ongoing treatment burden.
The physician gains earlier access to patient sleep hygiene information and can
therefore prioritise those patients who need to be seen first; ensuring those in the most
need of the service will have the shortest wait times. It is also forecasted that patient
satisfaction with the service will increase as during the wait time for an appointment they
are able to self-monitor their condition, Therefore the online sleep diary has a number of
benefits, namely;
1. the data contained within the diary is presented in a summarised, readily
accessible format for both physicians and patients
2. The diary contents are available at any internet access point and in real time
(subject to security precautions)
3. The diary facilitates the easy development of a database of sleep patterns and
this can be used for historical data analysis.
4. The online diary has all the advantages of digital data such as reuse, multiple
storage locations and easier transferability of data to other medical professionals
and statistical analysis.
This paper will discuss the construction of the online diary and its importance to
sleep hygiene.
2.1. Sleep hygiene
Good sleep hygiene helps to ensure good quality sleep. The guidelines for good sleep
quality include having consistent sleep and wake times, avoiding caffeine, nicotine and
alcohol before bedtime, avoiding heavy meals close to bedtime, exercise and sleeping in
a darkened quiet room (Stepanski & Wyatt, 2003; The Boston Consulting Group, 2003).
People who do not follow the sleep hygiene guidelines tend toward having poorer quality
sleep, with the extent of sleep quality degradation being dependent upon the individual
and the number of sleep hygiene guidelines not followed (Stepanski & Wyatt, 2003).
Brown, Buboltz Jr and Soper (2002) found that increasing awareness of sleep hygiene
through education did impact favourably on the sleep quality of healthy university
students, with Bootzin and Stevens (2005) describing the regularising of sleep patterns as
a powerful means of increasing sleep quality. However the following of good sleep
hygiene rules in the presence of a sleep disorder such as insomnia is not enough on its
own to remove excessive daytime sleepiness (Stepanski & Wyatt, 2003).
The sleep hygiene of a person is determined by looking at sleep patterns over a
two week period, documented in a sleep diary that is filled in every day. These sleep

Knowledge Management & E-Learning: An International Journal, Vol.2, No.2. 191
patterns are expressed for a health professional in a number of standard sleep measures,
described in the development of the online sleep diary section. Lifestyle factors such as
caffeine and medication use may also be included in a sleep diary, along with indicators
of mood on awakening.
Better quality sleep information is obtained when a sleep diary is filled out every
day. This ensures that the person has the best recall of sleep quality and timing of sleep,
Libman, Fichten, Bailes, and Amsel (2000) stating that questionnaires looking at
respective sleep patterns are susceptible to memory distortion, whereas a sleep diary
filled in every day has the ability to capture day to day variations, highlighting variations
that may indicate problems such as sleep deficits in sleep patterns. This means that the
recording of a persons sleep habits over a two week period in a sleep diary gives a
baseline of a person’s sleep patterns with greater precision than retrospective sleep
quality questionnaires.
Disadvantages of a sleep diary is that a person may change their sleep patterns in
reaction to the self-monitoring and the imposition of filling in the diary day to day
(Libman, et al., 2000). However a sleep diary is the most widely used, practical and
economical method of gauging sleep patterns (Lacks & Morin, 1992).
2.2. Benefits of a sleep diary
The benefit of a sleep diary is that it provides a tool to gather the details of sleep patterns
using a range of easily understood questions in a simple format. While the gathering of
day to day information requires commitment from the patient, the information gathered
provides an insight into the patient’s lifestyle and sleep habits. This information may
allow a physician to suggest lifestyle changes, for instance lowering caffeine intake later
in the day to reduce sleep disorder symptoms. Another benefit of a sleep diary is that it is
less intrusive than a retrospective sleep questionnaire the patient fills in at a clinic. The
patient does not need to leave their home and entries can be made as soon as the patient
arises potentially improving the quality of the data and removing the stress of trying to
recall past events in a waiting room.
Obstructive sleep apnea (OSA) is a common disorder. People with sleep apnea
stop breathing repeatedly during their sleep (a apnea) or have episodes of abnormally
shallow breathing (hypopnea), as many as hundreds of times in a single night (Young,
Peppard, & Gottlieb, 2002). In approximately five percent of patients (Guilleminault &
Philip, 1996) of OSA cases persistent excessive daytime sleepiness continues despite
compliant treatment. Santamaria et al. (2007) suggest that in this case the existence of
bad sleep hygiene and coexisting sleep disorders should be investigated. Coexisting
sleep disorders typically worsen symptoms of excessive day time sleepiness. The
effective use of a sleep diary by a physician may be used to diagnose a coexisting sleep
disorder as well explore sleep hygiene issues. In 8 percent to 43 percent of older OSA
patients the coexisting condition is insomnia (Smith, Sullivan, Hopkins, & Douglas,
2004) . Once a coexisting condition is diagnosed, treatment maybe carried out,
potentially reducing the patient’s symptoms to a level where the need for invasive OSA
treatment can be removed (Smith, Sullivan, et al., 2004).
2.3. An online approach
The advantage of an online approach from the current pen and paper method has been
mentioned earlier in this paper and the increased use and acceptance of the Internet is
demonstrated by the following statistic. In the 2007 period 77 percent of Queensland

192 Blake, J., & Kerr, D.
homes had home internet access, which had increased by five percent from the 2006
period (Queensland Government Chief Information Office, 2008a). Minimal difference
was shown in internet use between genders. These statistics show strong growth in
computer use in over 65 year olds, their internet use having grown strongly in the year to
44 percent a 6 percent increase (Queensland Government Chief Information Office,
2008a). The percentage of home internet user’s and the strong growth figures show that
online forms are a practical alternative to paper based forms for a large proportion of this
population.
One of the difficulties of an online IT approach is the need to design the system
for an unknown user. Users of an online system will access it through a broad variety of
connection mechanisms, with a wide variety of hardware and technical skill levels. This
compares to the development of an organisational system with standardised connection,
hardware and a known minimum technical standard (Taylor, Wade, & England, 2003).
Useability must be a primary objective of an online tool, with Guenther (2004) stating
that having a clear set of objectives for the user helps to make the online system high
value. This project has two different sets of users, physicians and patients, so the online
tool has to meet two different sets of objectives and expectations adding to the
complexity of development. What the user wants to achieve from the site must also be
considered (Weir, McKay, & Jack, 2007). This project needs to design the online tools to
look and feel like a solid health orientated instrument in order to achieve user satisfaction
for both groups. In the patient’s case the tool needs to feel like an application that will
provide good information to themselves and the physician, while in the physicians case
the tool should provide a set of quality information in an easy to assimilate format.
3. Design and development methods
The concept of an online sleep diary was driven by a series of three one hour interviews
with the director of a public Sleep Investigation Unit in Brisbane, Australia to discuss the
sleep disorder diagnostic process. A convergent interviewing method as described by
Dick (2002) was used, as an informal interviewing technique that is useful when the
researchers are in some doubt about the information which is to be collected. Notes and
impressions from the interviews were written in a journal and emailed to the interviewee
for confirmation that these were aligned with what they intended to convey. An online
search was carried out for existing online sleep diaries was carried out, a list of reviewed
sleep diaries is contained in table one. Most of these sleep diaries contained the same
elements, bed and wake times and questions on mood, caffeine intake and exercise.
However the difference with our approach is the focus on both the patient’s and
physician’s information needs. The majority of the sleep diaries accessible on the
Internet are pen and paper designed to be printed and then completed. The sleep diary
designed in this project offers coverage of reasons for waking, mood, a graph for patient
information and a concise report for the physician.
A systems development life cycle approach was used to develop the software,
using a rapid prototyping method, where a prototype of the software is developed quickly
and goes through a number of iterations in development. This prototype is thrown out at
the end of the development cycles and a new robust application coded (Strachan, 2006).
A requirements document with the specifications of the new system detailed using
Unified Modelling Language (UML) with an object oriented approach was produced.
Using this document as a template a paper prototype was produced for approval, by the
director of the sleep clinic. The suggested changes were then incorporated in a non-
functional prototype built in Hypertext Markup Language (HTML) and Javascript. This

Knowledge Management & E-Learning: An International Journal, Vol.2, No.2. 193
prototype was placed online and comments requested from two directors of Australian
sleep clinic’s and sleep researchers, two in Australia, one in New Zealand and one in
United Kingdom. The suggested changes were detailed and the online sleep diary sent
for coding by an external software development house. The external software
development house was an industry partner in the project and they were sent the software
requirements document and the link for the online prototype sleep diary.
Table 1 Online sleep diaries reviewed
Organisation
Link
Date
accessed
Mode
Sanofi-aventis
Inc
http://www.shuteye.com/sleep-solutions/
sleep-patterns/sleep-diary.aspx
7 May
2008
Printed
American
Academy of
Sleep Medicine
http://www.sleepeducation.com/pdf/
sleepdiary.pdf
7 May
2008
Printed
www.sleepdiary
.com
http://www.sleepdiary.com/
7 May
2008
Online
Memb-
ership
National Heart,
Lung and Blood
Institute
http://www.nhlbi.nih.gov/health/public/
sleep/starslp/teachers/sleep_diary.htm
7 May
2008
Printed
Eyre Peninsula
Division of
General
Practice
http://www.epdgp.org.au/Download%
20documents/Insomnia%20Management
/Insomnia%201B%20-Sleep%20Diary.pdf
8 May
2008
Printed
Loughborough
Sleep research
centre
http://www.lboro.ac.uk/departments/hu/groups
/csru/pdf/Daily%20Sleep%20Diary+Hygiene
.pdf
8 May
2008
Printed
National Sleep
Foundation
http://www.kintera.org/atf/cf/%7BF6BF2668
-A1B4-4FE8-8D1A-A5D39340D9CB%7D
/SleepinessDiary2.pdf
8 May
2008
Printed
The development of an online application gives the form designer control over the
order the form is filled in which means that the user can be constrained to the required
pattern of information/collection. An online application also provides an opportunity to
conduct validation of the entered data at the point of entry. Using validation in the sleep
diary means that the physician does not need to question the patient about the data
contained in the sleep diary, but may accept that the sleep statistics reflect the sleep
patterns entered by the patient. The provided date and time stamping provide guidance to
the physician if any there was any delay between a sleep event and the data entry.
Once the sleep diary is developed each form completion is cost effective,
allowing large numbers of respondents or many repeated iterations of the form to be
filled in. As the data is captured, automatically stored and is manipulated by the online
form, data analysis is low cost and happens in real time for each form (Haynes, Sackett,
Guyatt, & Tugwell, 2006). The automatic storage of data, gives an opportunity to collect
good quality validated data for future research. This is important as at the moment no
aggregated analysis is carried out on the present pen and paper sleep diary. Anecdotal
evidence suggests that manually computing the data from a paper based sleep diary and
the data entry of the information into a database requires a large time commitment from

194 Blake, J., & Kerr, D.
clinic staff. This means that the routine collection of sleep diary information to build an
evidence base is unlikely to be given a priority outside of a specific research project.
To display information online, equity of access must be considered so that online
tools have utility for the sight, hearing and physical impaired, users with little technical
expertise must also be catered for. Wagner, Hassanein, and Head (2010) has suggested a
number of guidelines for older users of web sites, including making sure visual elements
are large enough to be seen and deciphered. He suggests that using elements that contrast
highly with the background such as black elements on a white background assists. An
uncluttered web page without too many elements claiming attention helps the user to
make sense of the page, also using graphics only when necessary to illustrate or add to
the site’s function (Yen, Hu, & Wang, 2007). The expected age range of the users of the
online sleep diary is fairly broad and computer literacy is variable. Most of the potential
patients are greater than 45 years old and reasonably computer literate but to improve
equity of access the sleep diary must be as accessible as possible across the whole
spectrum of potential patients.
In the sleep diary interface we have used maximum contrast of black text on a
plain white background, with a sans serif font and an uncluttered background. The
uncluttered background means that the sleep diary can be personalised with for example
an organisations logo without disturbing the readability of the questions. The plain
background also helps to minimise the size of web application which means that those
patients with slow download speeds are not penalised by having to wait for a graphic to
download.
A user tries to make logical sense of the web page displayed at first glance, so that
the design of the page must make logical sense, for instance headings are in a larger font.
Design elements which are related need to be gathered together graphically, for example
a question is contained within a frame. The graphical treatment of these elements needs
to be consistent and predictable throughout the web site to aid usability (Williams, 2000).
A linear web site plan where the user moves through the web application page by page
helps to orientate the user so that they are aware of where in the web site they are
(Guenther, 2004; Yen, et al., 2007).
The heuristic evaluation rules for websites detailed by Sharp, Rogers, and Preece
(2007) were employed. The website has internal consistency, with phases carrying the
same meaning throughout the web site with simple dialog. To aid internal consistency,
formatting of pages fonts, font sizes and font colours are consistent. Shortcuts have not
been used, as the sleep diary has a simple linear format which must be followed to gather
complete information. The user’s memory load is minimised with no information being
required to be remembered from one part of the web dialog to the other. Validation will
exist within the web forms so that for example a wake time before a sleep time can not be
chosen, validation will also check each page for completeness. The feedback to the user
from the sleep diary is the presentation of the sleep pattern graphic representing entered
sleep patterns. To ensure data quality an incomplete sleep day entry will be discarded.
Screen shots of the online sleep diary are used in this section. The entry page of
the online sleep diary is a log on page providing the facility to differentiate between
physicians and patients and the means to authenticate users through the use of an
identification number and user name. Differentiating between physicians and patients is
important to customise their interaction with the web site. To facilitate the physician’s
use of the tool the physician goes directly from log on to the sleep statistic page for the
entered patient number. The patient will be taken to the next page of their current sleep
diary, so that they may continue to complete their sleep diary.

Knowledge Management & E-Learning: An International Journal, Vol.2, No.2. 195
At the first visit to the web site the patient is required to complete a consent form.
This is necessary to ensure that informed consent is given to the use of de-identified data
being used to form an evidence database. The withholding of permission by a user
however has no impact on how they may use the web application. The online sleep diary
therefore fulfils the function of a data collection point.
Figure 1. Bed time page
The bed time page shown in figure one requires the user to pick from a drop down
box, the time they went to bed, the time they settled for sleep and an estimate of how long
it took them to go to sleep. Bootzin (2005) suggests that for good sleep hygiene a
minimum amount of time is spent in bed before settling to sleep, no longer than ten
minutes. This is so that bed time is associated with dropping off to sleep quickly. Sleep
on-set latency is the amount of time between the person settling for sleep, for example
turning of the light and the time when sleep occurred. People with insomnia tend to
overestimate sleep latency while people without insomnia tend toward estimating the
correct amount of time taken to fall asleep (Smith & Trinder, 2000). Sleep latency is
used as an indicator of a sleep disorder. A short sleep latency time indicates a sleep
deficit, while a long sleep latency time may indicate insomnia.
The wake time web page is shown in figure two, these four values form part of
the sleep statistics used by sleep physicians to confirm a diagnosis. The subtraction of
the time the user got up from bed from the time they went to bed gives the time available
for sleep. To produce a value of the total sleep period statistic, the time of sleep onset to
the time of final awakening is calculated. Total sleep time is the total sleep period less
the time spent awake during the sleep period. Total wake time is the addition of wake
time during the period available for sleep. Sleep efficiency is a percentage measure of
the total sleep period divided by the total sleep time. These sleep statistics help the sleep
physician to assess the quality of sleep and some sleep habits.

196 Blake, J., & Kerr, D.
Figure 2. Getting up time
Figure three the sleep quality page provides explanations for waking after sleep
onset and an inability to maintain sleep. Sleep environment factors such as being woken
by noise or light and sleep disorder factors such as being woken by choking or restless
legs are included. This allows the physician to either make suggestions to improve the
sleep environment, or offer advice on relaxation techniques or may provide evidence
toward a diagnosis of a sleep disorder. This page also provides an opportunity for the
user to perform some functional analysis, for example if sleep environment factors are
consistently keeping them awake or affecting their ability to maintain sleep. In this
instance the consultation provides an opportunity to ask the sleep physician what they can
adjust to change the waking pattern. If choking or suffocating is checked as a reason for
waking then a pop-up page is used which requests more information on the episode. This
information aids the physician in diagnosing the reason for the feeling of choking or
suffocating.
Lack of refreshing sleep and excessive daytime sleepiness can manifest itself as a
feeling of irritability and apathy, and is an indicator if excessive daytime sleepiness is a
problem in the user’s life, the sleep quality page is shown in figure four. The data
contained in this page can be used to demonstrate the importance of compliance with
treatment, if the user is reporting waking feeling tired and irritable. This data is also
useful for research into the impact of sleep patterns on mood.
The statistics page shows a graph of the sleep patterns and a summary of sleep
measurements such as sleep efficiency, sleep latency and the number of times the user
woke after falling asleep. The presentation of the complete set of summary sleep
measures in a format which is immediately usable to the physician will facilitate the
physician’s diagnosis by removing time pressures and ensuring that the information
contained in sleep diary is used efficiently.

Knowledge Management & E-Learning: An International Journal, Vol.2, No.2. 197
Figure 3. Sleep quality
Figure 4. Mood page
The current paper based sleep diary as stated does not present information in a
format that the lay person can understand. The online sleep diary in this project presents
sleep patterns as an easy to understand multi-coloured horizontal bar graph, with time
along the x-axis. Midnight is the centre of the x-axis to allow the comparison of the
regularity of bed and waking up times important in sleep hygiene. This graph builds day

198 Blake, J., & Kerr, D.
by day as the patient completes each day’s diary entry. The different colours within the
bars represent different states, such as awake during sleep time, sleep latency and sleep
time. Therefore the physician can gain a view of the patients sleep patterns quickly while
the patient gains access to the information on their sleep patterns presented in a simple
graphical format.
Figure 5. Sleep graph
One of the complications with the implementation of this application is the need
to fit the application inside guidelines set by the government for patient privacy, for
instance a patient number cannot be used as an identifier. The need for a different
number is to satisfy the National Privacy Principles stated in the Queensland
Governments information architecture for the Department of Health (Queensland
Government, 2001) which was last reviewed in April 2008 (Queensland Government
Chief Information Office, 2008b) which states that an identifier that has been assigned by
an agency cannot be adopted by an outside application. A user number which is unique
and different to a patient number will be assigned. The assignment of a user number by
an application outside of our control means that there is no link to identifying user data
held in the projects database.
4. Conclusions
The initial reaction to the implementation of the sleep diary on an external server has
been favourable with a number of organisations outside of Queensland Health expressing
interest. The online sleep diary is intended to form part of a group of online tools for use
by patients and general practitioners to provide information to the users in a readily
accessible, easy to understand format. These tools will provide patients with an avenue
to self-assess sleep patterns and habits in a readily assimilated graphical format to support
good health. It is also an aim that the physicians will gain standard, validated tools for
patient appraisal in sleep disorder treatment; and online tools which facilitate the
collection and distribution of high quality data to provide support to physicians in patient
assessment.

Knowledge Management & E-Learning: An International Journal, Vol.2, No.2. 199
The current utility of the pen and paper sleep diary is low, with the physicians
unable to take the time to use this tool as effectively as they would wish. The patient also
gets little reward for the commitment to filling in the dairy every day for a fortnight, as
information is difficult to extract without specialist knowledge. Therefore an online sleep
diary offers a number of benefits, as both physicians and patients receive readily
assimilated information. The physicians have access to the information earlier in the
diagnostic interaction. While the patients gain self-knowledge which allows them to
potentially become partners with the physician in the management and/ or treatment of
symptoms. The provision of increased patient knowledge at the first consultation means
that the physician has the opportunity to talk to the patient about their specific sleep
hygiene practises during the first consultation. Therefore this consultation moves away
from a mainly information gathering exercise toward a collaboration between the patient
and physician.
Wait times for an appointment with a sleep physician may be extended Flemons
et al.(2004) state that in United Kingdom a wait of six months for non-urgent cases is
average, with an average wait time in Australia of nine weeks. An online diary used in a
sleep clinic setting has the ability to bring forward information gathering on a patient’s
sleep hygiene to before a patient’s first appointment with a sleep physician. Physician
access to an increased amount of patient knowledge early in the patient physician
interaction means the physician can better assess the urgency of a patient’s need for
services. Another benefit to early patient information is that a recommendation that the
patient see another health professional during the wait time can be made. For instance a
sleep diary coupled with a physician’s assessment is the primary diagnostic tool for
insomnia (Lacks & Morin, 1992; Morin, Colecchi, Stone, Sood, & Brink, 1999), so that
the sleep physician may be able to recommend the patient visits a psychologist for help
with insomnia without the need for a extended physical appointment. This means that the
patient is spared an extended wait for service, only to be told they need to wait for an
allied health professional. This short cut potentially increases satisfaction with the
service provided and the physician has increased time to see other patients.
The user is able to enter the date of the sleep event in the online dairy, however
the sleep entry is also date and time stamped. This date stamping is to provide the
physician with a guideline to the quality of the sleep information contained in the diary.
As recollection of past events may degrade the quality of the provided information
(Libman, et al., 2000).
The online sleep diary will produce a summary report which may be printed both
for the person filling in the diary and a physician. This summary report gives access to
sleep statistics, such as mean sleep efficiency, mean sleep length, range of sleep latency
and sleep duration in a quickly assimilated format which has direct utility for assistance
in a diagnosis of a sleep disorder. The summary report may also be filed in a patient
record to provide a baseline for future sleep diary reports for the physician and patient.
The summary report of sleep statistics also plays a role in the formation of the evidence
base as the statistics give a means to perform cross patient comparisons using well
defined parameters of sleep characteristics. The statistics along with the base data will
allow the development of a database which facilitates the analysis of the data in a holistic
way. This database will expedite the development of an application such as an Artificial
Neural Network which can draw inferences from the data to provide an objective second
opinion for the physician for a sleep disorder diagnosis.
A summary report of sleep hygiene practises may also be useful for the user to
take to their primary care physician if the user is concerned about excessive daytime

200 Blake, J., & Kerr, D.
sleepiness. Potentially this means that primary care physicians may refer patients with
moderate symptoms of a sleep disorder to a sleep specialist as sleep disorders are under
diagnosed in all but the most symptomatic patients (Kramer, Cook, Carlisle, Corwin, &
Millman, 1999). The online sleep diary may also be used by primary physicians to
explore alternative explanations such as insomnia, or poor sleep hygiene for symptoms of
depression such as fatigue.
The facility to export the data contained in the online sleep diary in an eXtensible
Markup Language (XML) format will also be provided. This means that organisations
other than that hosting the sleep diary can receive patient data in an electronic format,
facilitating use of electronic record keeping.
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