Internal medicine is a team sport. On any given day, the care plan for one patient may involve a physician, bedside nurse, pharmacist, physical therapist, case manager, social worker, nutritionist, and consultants, all working in parallel with different workflows, priorities, and documentation habits.

That’s also the challenge.

Many breakdowns in inpatient care are not knowledge failures, they are coordination failures, the right information exists, but it is scattered across notes, flowsheets, orders, and verbal updates. Interprofessional care can feel like everyone is doing the right things, just not always in the same direction.(1)

Data analytics does not replace teamwork. It makes teamwork easier to coordinate by turning day to day care into shared signals the entire team can see, interpret, and act on, especially in internal medicine, where decisions depend on trends over time (vital signs, labs, mobility, fluid balance, oxygen needs, mental status, medication changes, and discharge readiness).

The World Health Organization has emphasized the importance of collaborative practice as part of strengthening health systems. (2) The question is how do we turn interprofessional care into a reliable daily routine? A practical answer is shared metrics, shared visibility, and shared accountability.

What Interprofessional Analytics Means in Practice

Interprofessional analytics is not just building a dashboard, It is creating a shared view of the patient journey that multiple disciplines trust and actually use.

This is not meant to replace clinical judgment or a full chart review. It replaces a common default workflow, fragmented updates (each discipline in a different part of the chart), memory based rounding, and last minute surprises. Clinical dashboards and shared displays are most useful when they make key information easier to find, track, and act on.(3)

A simple framework:

  • Shared goals (clinical, functional, and discharge goals)
  • Shared definitions (what ready for discharge means, what mobility achieved means, what medication reconciliation complete means)
  • Shared signals (the few indicators that matter most)
  • Shared actions (who does what when a signal changes)

When teams agree on the same signals, care becomes more consistent, because it is easier to align priorities across roles and across shifts.

Why discharges get delayed:

Even in well run units, discharges can get delayed by a day or more when key tasks and decisions are spread across different roles, notes, and workflows. Studies on general medicine units and medical teaching wards consistently find recurring barriers such as pending procedures/results, consult recommendations, facility placement, and gaps in communication/standardization.(4,5)

Common examples include:

  • A physical therapy evaluation happens late, so mobility needs are discovered late
  • Medication reconciliation reveals insurance or coverage barriers late
  • Home oxygen requirements are unclear, so durable medical equipment is not arranged early
  • Family/caregiver teaching is not scheduled until the last minute
  • A key lab trend or oxygen requirement changes, but different team members notice at different times

These are common everyday failure points, not because people are not trying, but because information is not consistently visible in the same place at the same time to the whole team.

Data analytics helps by turning discharge readiness into a trackable, shared checklist rather than an informal impression.

A Shared Rounding Checklist to Replace Fragmented Updates

Shared signals simply means a few indicators the whole team agrees are important, tracked the same way, reviewed at the same time, and paired with an action. When teams use structured tools and shared signals together, important changes are noticed earlier and acted on more consistently.(6)

If you could track only a few elements daily, visible to physicians, nursing, physical therapy, pharmacy, and case management, these are high yield:

Clinical stability

  • Oxygen requirement trend (not just the current value)(7)
  • Vital sign stability flags (for example persistent tachycardia or hypotension)(7)
  • Key lab trend tied to the diagnosis (for example creatinine for acute kidney injury, sodium for hyponatremia)
  • New fever, pending cultures, and antibiotic day of therapy(8)

Function and safety

  • Mobility status today vs yesterday (assistance level and/or ambulation distance, as documented)(6)
  • Delirium risk indicators (sleep disruption, restraints, sedating medications)(9)
  • Falls risk plus any recent fall/near fall documentation(10)

Medications

  • High risk medications started or stopped (for example anticoagulants, insulin, opioids)(11)
  • Medication reconciliation status (complete vs pending)(12)
  • Barriers (prior authorization, cost, pharmacy availability)(13)

Discharge logistics

  • Expected discharge date and whether the plan is on track (or at risk of delay).(14)
  • Disposition target (home, inpatient rehabilitation, skilled nursing facility)(15)
  • Blocking items, each with an owner (physical therapy evaluation, home services, transportation, durable medical equipment, patient/caregiver teaching)(14,15)

The point is alignment, so the whole team is working from the same picture.

Where the Data Comes From  

Most of these elements already exist in the EHR:

  • Flowsheets (nursing documentation, vital signs)
  • Orders (oxygen, consults, imaging)
  • Medication administration records
  • Notes (case management, physical therapy/occupational therapy)
  • Labs (time series)

In many cases, the hardest part isn’t building a model, it’s combining the right information and standardizing it so it supports real decisions. That requires attention to missing data and differences in documentation across the care team.(3)

Why This Matters

Teamwork is not just a soft skill in healthcare, it is a safety issue. Research on teams and teamwork in healthcare links effective teamwork to safer, higher quality care.(1)

TeamSTEPPS, developed collaboratively by the US Department of Defense and the Agency for Healthcare Research and Quality, is an evidence based teamwork system designed to support communication and teamwork in healthcare settings.(16)

When the whole team reviews the same key indicators each day, issues are caught earlier and plans stay aligned.

Three Small Projects to Start With

For residents interested in building analytic thinking (and potentially creating a quality improvement project), here are three practical starting points. The goal is to help the team agree on a small set of shared signals that are reviewed together more frequently, during interdisciplinary rounds, while still using the full electronic health record and clinical judgment for comprehensive patient care.

1) Map common reasons for delayed discharge 
Track the most common reasons planned discharges are delayed by 24 hours or more (for example physical therapy timing, medication access, durable medical equipment, pending imaging). On rounds, identify the top blocking item and assign an owner. (for example PT, pharmacy, case management, or the primary team), and revisit it the next day. Delayed discharge has well described causes and consequences, and many are workflow related.(17)

2) Track physical therapy timing and mobility trends 
Measure the time from physical therapy consult order to first physical therapy evaluation, and track mobility status at discharge over time. Share a simple monthly trend with the interdisciplinary team so bottlenecks become visible and timing can improve. Earlier PT input has been associated with shorter length of stay and lower care needs on discharge, and mobility programs in general medicine have shown improvements in outcomes in some settings.(18,19)

3) Do a medication friction audit 
Identify common medications associated with discharge delays (prior authorization, cost, availability). Partner with pharmacy to create an early high friction medication list, so barriers are recognized and addressed earlier in the hospital stay.(12,20)

How to make it shared across the care team:

  • Review the key signals during interdisciplinary rounds.(21)
  • Display them in a shared location (unit whiteboard, EHR patient list column, or a simple rounding checklist).(3,21)
  • Keep it to a few items so the team actually uses them, and pair each item with a clear next step and owner so it drives action, not just awareness. (15,21)

Interdisciplinary bedside rounds and structured rounding processes can improve patient centeredness and team collaboration, but results vary, especially when the process is not clearly defined. That’s why the team needs to agree on the same terms, goals and criteria.(20)

Limitations and how to use analytics safely

Analytics can unintentionally widen gaps if teams rely on dashboards without checking the context.  

Limitations include:

  • Missing data driven by documentation differences
  • Bias in who receives services (for example consult patterns)
  • Alert fatigue (too many flags leads to distrust)
  • Over reliance on a score without clinical context

How to reduce risk:

  • Keep the dashboard small (a few high yield signals only).
  • Use clear, consistent definitions so everyone documents and interprets signals the same way.
  • Pair each signal with an action and owner (so it leads to a next step, not just a flag).
  • Review signals during interdisciplinary rounds for shared visibility.

High functioning teams use analytics as decision support, not decision replacement.

Conclusion

In internal medicine, excellent care is not only about diagnosis and treatment, it is also about coordination. Data analytics gives teams a shared language, trends, definitions, and measurable progress. A shared patient snapshot helps teams align around the same signals, the same definitions, and the same next steps, and that is a practical use of data analytics that fits in day to day inpatient care.(1)

This mindset is immediately useful, it helps you translate complex inpatient care into clear signals the whole team can act on, while still seeing the patient as a person, not a dashboard.

References

  1. Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. The American psychologist, 73(4), 433–450. https://doi.org/10.1037/amp0000298
  2. World Health Organization (2010). Framework for action on interprofessional education and collaborative practice. World Health Organization. World Health Organization. https://iris.who.int/handle/10665/70185
  3. Khairat SS, Dukkipati A, Lauria HA, et al. The Impact of Visualization Dashboards on Quality of Care and Clinician Satisfaction: Integrative Literature Review. JMIR Hum Factors 2018;5(2):e22 doi: 10.2196/humanfactors.9328
  4. Ragavan, M. V., Svec, D., & Shieh, L. (2017). Barriers to timely discharge from the general medicine service at an academic teaching hospital. Postgraduate medical journal, 93(1103), 528–533. https://doi.org/10.1136/postgradmedj-2016-134529
  5. Okoniewska, B., Santana, M. J., Groshaus, H., Stajkovic, S., Cowles, J., Chakrovorty, D., & Ghali, W. A. (2015). Barriers to discharge in an acute care medical teaching unit: a qualitative analysis of health providers' perceptions. Journal of multidisciplinary healthcare, 8, 83–89. https://doi.org/10.2147/JMDH.S72633
  6. King, H. B., Battles, J., Baker, D. P., Alonso, A., Salas, E., Webster, J., Toomey, L., & Salisbury, M. (2008). TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety. In K. Henriksen, J. B. Battles, M. A. Keyes, & M. L. Grady (Eds.), Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Agency for Healthcare Research and Quality (US). http://www.ncbi.nlm.nih.gov/books/NBK43686/
  7. National Institute for Health and Care Excellence. (2007). Acutely ill adults in hospital: recognising and responding to deterioration (CG50).
  8. Centers for Disease Control and Prevention. (2019). Core Elements of Hospital Antibiotic Stewardship Programs.
  9. Kalish, V. B., Gillham, J. E., & Unwin, B. K. (2014). Delirium in Older Persons: Evaluation and Management. American Family Physician, 90(3), 150–158.
  10. Partners HealthCare System Fall Prevention Task Force. (n.d.). The Morse Fall Scale: Training module [PDF]. Brigham and Women’s Hospital (Fall TIPS Toolkit). https://www.brighamandwomens.org/assets/BWH/medical-professionals/pdfs/fall-tips-toolkit-mfs-training-module.pdf
  11. Institute for Safe Medication Practices. (2024). ISMP list of high-alert medications in acute care settings [PDF]. https://www.ismp.org/system/files/resources/2024-01/ISMP_HighAlert_AcuteCare_List_010924_MS5760.pdf
  12. Gleason, K. M., Brake, H., Agramonte, V., & Perfetti, C. (2011). Medications at transitions and clinical handoffs (MATCH) toolkit for medication reconciliation (AHRQ Publication No. 11(12)-0059). Agency for Healthcare Research and Quality. https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/quality-improvement/learn-about-quality-improvement-match.pdf
  13. Forshay, C. M., Mellett, J., Worley, M. M., Carnes, C. A., Fernandes, A., & Jordan, T. A. (2023). Implementation and evaluation of a prior authorization workflow for new-start inpatient medications in preparation for discharge. Hospital Pharmacy, 58(2), 188–193. https://doi.org/10.1177/00185787221127610
  14. Radhakrishnan, N. S., Lukose, K., Cartwright, R., Sleiman, A., Matey, N., Lim, D., LeGault, T., Pollard, S., Gravina, N., & Southwick, F. S. (2022). Prospective application of the interdisciplinary bedside rounding checklist ‘TEMP’ is associated with reduced infections and length of hospital stay. BMJ Open Quality, 11(4), e002045. https://doi.org/10.1136/bmjoq-2022-002045
  15. Institute for Healthcare Improvement. (2015, February). How-to guide: Multidisciplinary rounds (Updated February 2015). Institute for Healthcare Improvement. https://www.mnhospitals.org/wp-content/uploads/Portals/Documents/patientsafety/Patient%20Family%20Engagement/IHIHowtoGuideMultidisciplinaryRounds.pdf
  16. King, H. B., Battles, J., Baker, D. P., Alonso, A., Salas, E., Webster, J., Toomey, L., & Salisbury, M. (2008). TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety. In K. Henriksen, J. B. Battles, M. A. Keyes, & M. L. Grady (Eds.), Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). Agency for Healthcare Research and Quality (US). http://www.ncbi.nlm.nih.gov/books/NBK43686/
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  19. Bergbower, E. A. S., Herbst, C., Cheng, N., Aversano, A., Pasqualini, K., Hartline, C., Hamby-Finkelstein, D., Brewer, C., Benko, S., & Fuscaldo, J. (2020). A novel early mobility bundle improves length of stay and rates of readmission among hospitalized general medicine patients. Journal of community hospital internal medicine perspectives, 10(5), 419–425. https://doi.org/10.1080/20009666.2020.1801373
  20. Society of Hospital Medicine. (2014). MARQUIS implementation manual: A guide for medication reconciliation quality improvement (Addendum added August 2017). Society of Hospital Medicine. https://www.hospitalmedicine.org/globalassets/clinical-topics/clinical-pdf/shm_medication_reconciliation_guide.pdf
  21. Heip, T., Van Hecke, A., Malfait, S., Van Biesen, W., & Eeckloo, K. (2022). The Effects of Interdisciplinary Bedside Rounds on Patient Centeredness, Quality of Care, and Team Collaboration: A Systematic Review. Journal of patient safety, 18(1), e40–e44. https://doi.org/10.1097/PTS.0000000000000695