Background: MS-CQI is the first multi-center improvement research collaborative for MS care. MS-CQI was a three-year study (2018-2020) to evaluate system-level performance variation and improve MS population health outcomes. Four MS centers participated, following approximately 5,000 people with MS (PwMS). The COVID pandemic onset occurred approximately half-way through the final year of the study. Telehealth methods that were not used prior to the onset of COVID were quickly incorporated into patient care during this time. In response, measures of telehealth utilization were added to the study in order to study system level variation in telehealth utilization and associated clinical outcomes for COVID-era MS care during the last 6 months of the MS-CQI study. Objectives: Study system level variation in telehealth utilization and associated clinical outcomes for COVID-era MS care during the last 6 months of the MS-CQI study. Methods: Electronic Health Record (EHR) data from clinical encounters at the four participating MS-CQI centers was abstracted for January-June 2020. Participants were adults ?18 years who were seen during the pandemic portion of the study either in person or via a telehealth method such as phone or video. Chi-square tests were used to assess associations across centers and different types of telehealth utilization variables and ANOVA was used for continuous variables. Associations between telehealth visits, relapses, and Disease Modifying Therapy (DMT) were determined through binary logistic regression analyses. Results: 1,866 PwMS were in our analysis with a majority of the population being female (75%), having RRMS (81%), and an average age of 49. Telehealth utilization increased dramatically throughout the COVID period and in-person visit utilization decreased. Controlling for individual factors and covariates and using the highest volume MS-CQI center as the referent group, regression analyses identified significant center effects on telehealth utilization, relapses and DMT with comparator sites ORs of 6.84 (95% CI: 2.5, 18.4) and 11.07 (95% CI: 6.1, 19.7) respectively. Video and in person telehealth visits were associated with decreased odds of relapse (OR = 0.45; 95% CI: 0.22-0.94; OR=0.50; 95% CI: 0.25-0.98) and DMT use (OR = 0.53; 95% CI: 0.35-0.80; OR = 0.55; 95% CI: 0.38-0.80). Conclusions: Our findings provide initial evidence of telehealth utilization in four MS centers during the beginning of the COVID-19 pandemic. Adjusted analyses of population level data from the MS-CQI study identified significant geographic system-level variation in visit type utilization (telephone, video telehealth, in-person), relapses and disease modifying therapy (DMT) utilization. Significant associations between decreased odds of relapse and DMT use and telephone visit type. Findings suggest future inquiry and improvement efforts targeting PwMS in the telephone visit subgroup.