Digital supervision in the clinical learning environment: Characterizing teamwork in the electronic health record.

Background: Attending physicians in academic hospitals work in supervisory team structures with medical residents to provide patient care. How attendings utilize the electronic health record (EHR) to support learning through supervision is not well understood.

Objective: To compare EHR behavior on teaching versus direct care, including evidence of supervisory calibration to learners.

Methods: Cross-sectional study analysis of EHR metadata from 1721 shifts of hospital medicine faculty at a large, urban academic medical center, January to June 2022. Measures included total EHR time per shift, EHR time outside shift, and time spent on: note-writing, note review/attestation, order entry, and other clinical review. We assessed within physician differences across these service types and used multilevel modeling to determine whether these behaviors varied with resident physicians' experience, accounting for physician-specific signature behavior patterns.

Results: Attendings spent substantially less time in the EHR while on teaching service than on direct service (129 vs. 240 min; p < .001) and apportioned their work differently throughout the day. Physicians were less behaviorally consistent and varied more than their peers when on teaching service. Attendings calibrated their supervision to learners. Attendings logged 12.7% less EHR time when paired with more senior residents than postgraduate year 2 (PGY2) residents (137 vs. 120 min, p = .002). PGY1 presence was also associated with reduced EHR time, suggesting some delegation of supervision to senior trainees.

Conclusion: EHR behaviors on teaching service are highly variable and differ substantially from direct care; a lack of consistency suggests important opportunities to establish best practices for EHR-based supervision and create an effective clinical learning environment.