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BACKGROUND Telehealth, the delivery of health care through telecommunication technology, has the potential to address multiple health system concerns. Despite this potential, only 15% of pediatric primary care clinicians reported using telemedicine as of 2016, with the majority identifying inadequate payment for these services as the largest barrier. The COVID-19 pandemic led to rapid changes in payment and regulations surrounding telehealth, allowing for integration into primary care pediatrics. OBJECTIVE Due to limited use of telemedicine in primary care pediatrics prior to COVID-19, much is unknown about the role of telemedicine in pediatric primary care. To address this gap in knowledge, we examined the association between practice-level telemedicine use within a large pediatric primary care network and practice characteristics, telemedicine visit diagnoses, in-person visit volume, child-level variation in telemedicine use and clinician attitudes towards telemedicine. METHODS We analyzed electronic health record data from 45 primary care practices and administered a clinician survey to practice clinicians. Practices were stratified into tertiles based on rates of telemedicine use (low, intermediate, high) per 1000 patients per week during a two-week period (4/19-5/2/2020). By practice tertile, we compared (1) practice characteristics, (2) telemedicine visit diagnoses, (3) in-person visit rates to office, urgent care and emergency department, (4) child-level variation in telemedicine use and (5) clinician attitudes towards telemedicine across these practices. RESULTS Across pediatric primary care practices, telemedicine visit rates ranged from 5 to 23 telemedicine visits per 1000 patients per week. Across all tertiles, the most frequent telemedicine visit diagnoses were mental health (28-36% of visits) and dermatologic (15-28%). Compared to low telemedicine use practices, high telemedicine use practices had fewer in-person office visits (10 vs. 16 visits per 1000 patients per week, P=0.005), but overall more total encounters (in-office and telemedicine: 28 vs. 22 visits per 1000 patients per week, P=0.006). Telemedicine use varied with child age, race and ethnicity, and recent preventive care, but no significant interactions existed between these characteristics and practice-level telemedicine use. Finally, clinician attitudes regarding the usability and impact of telemedicine did not vary significantly across tertiles. CONCLUSIONS Across a network of pediatric practices, we identified significant practice-level variation in telemedicine use, with increased use associated with more varied telemedicine diagnoses, fewer in-person office visits, and increased overall primary care encounter volume. Thus in the context of the pandemic when underutilization of primary care was prevalent, higher practice-level telemedicine use supported pediatric primary care encounter volume closer to usual rates. Child-level telemedicine use differed by child age, race/ethnicity, and recent preventive care, building upon prior concerns about differences in access to telemedicine. However, increased practice-level use of telemedicine services was not associated with reduced nor worsened differences in utilization, suggesting further work is needed to promote equitable access to primary care telemedicine. CLINICALTRIAL