The past as prologue: future directions in clinical performance measurement in ambulatory care.

Physicians and other caregivers have articulated concerns about the completeness and focus of the current set of ambulatory care quality measures. In this commentary, we review some of the reasons why our current measures are not as useful, reliable, and accurate as they should be and examine the 2 major barriers to improvement: lack of adequate funding for formulation, development, and testing; and gaps in the completeness and adequacy of the current data sources. We explore some promising directions, including (1) measures of misuse and overuse, (2) measures of appropriateness and quality of procedures, (3) measures that are more directly actionable, (4) measures that are more nuanced and patient centered, and finally (5) measures that make full use of the added information in fully interoperable electronic health records. With modest private and public funding for comparative studies and consensus guideline development, formulation, and testing, and with the relatively rapid transformation taking place in current data systems, it is possible to move well beyond the rather limited, but still important, measures we currently have.