In 2021, the National Academy of Medicine called for further study of telehealth to help strengthen primary care as part of their “Implementing High-Quality Primary Care in the United States” report [1]. Past studies highlight a range of patterns in telehealth use by patient-level factors [2], but primary care practice–level capabilities, such as resources to enable telehealth, have not been systematically assessed. Organizational and contextual factors, such as a federally qualified health center (FQHC) designation and a practice’s neighborhood characteristics, may also be associated with telehealth use. We analyzed a national survey of US adult primary care practices to examine relationships between practice-level factors and telehealth adoption.

The median use of telehealth for practice encounters was 20% (IQR 10%-35%), and the median proportion of audio-only telehealth visits was 29% (IQR 17%-50%). High-telehealth-use practices were more likely to care for a high proportion of uninsured patients, to have expanded broadband access for patients, and to have trained patients to use telehealth (Table 1).

In multivariable regression analyses (Figure 1), a high payer mix of uninsured patients and high broadband expansion corresponded to higher telehealth use (P=.02 and P=.008, respectively), while rurality corresponded to lower telehealth use (P=.008). Audio-only telehealth use was higher among FQHCs compared to other practices (P=.02), and assisting patients with using telehealth was associated with both higher telehealth use and a smaller proportion of audio-only telehealth use (P=.002 and P=.001, respectively).

In this national study of primary care practices in 2022, we found that respondent practices serving the uninsured reported greater use of telehealth for patient encounters, and FQHCs used more audio-only telehealth. This suggests that low socioeconomic status populations had a higher need for telehealth and that cuts to audio-only reimbursement would disproportionately impact care for such patients. The “digital divide,” systematic barriers for accessing and using technology and telehealth among various populations [3], is a known issue for FQHC and rural populations [4,5], and our study provides national evidence that these practice-level factors are significantly associated with lower adoption of video-based telehealth.

Importantly, we found that the telehealth-enabling practices of training and assisting patients with using telehealth and broadband expansion were associated with higher telehealth adoption. In contrast, electronic health record integration for video visits, participation in alternative payment models that incentivize care quality, and practice ownership were not significant practice-level factors, contrasting with a prior study suggesting health system integration was linked to higher telehealth use at the physician level [6].

Limitations include potential nonresponse bias due to the modest response rate, though we used weights to account for this (sensitivity analyses of missing data are in Multimedia Appendix 1); that telehealth use is reported in aggregate rather than calculated from visit data, so could not be verified; and an inability to draw causal inference from cross-sectional analysis. Longitudinal analyses or controlled trials would provide stronger evidence and be able to describe any changes in significance of the identified factors for telehealth use over time.

These findings provide important national data for the design of policy and practice interventions to expand telehealth use. Practices focused on enabling telehealth appear able to meaningfully increase its uptake [7]. Federally, renewing the lapsed support for broadband accessibility is an important means to address the digital divide [8,9].