Research objectives: This dissertation examines the state of development of each of the eight core electronic health record (EHR) functionalities as described by the IOM and describes how the current state of these functionalities limit quality improvement efforts in ambulatory care settings. There is a great deal of literature describing both the potential of the EHR to improve quality of care and showing a lack of improvement associated with EHR use. This study examines the role that the state of development of EHR functionalities plays in the quality improvement. Study design: A qualitative study of four community health center (CHC) networks that provide EHR services to members and three CHCs from each network. Each network used different, commonly used and CCHIT certified EHRs. Sixty five hours of interviews were transcribed, coded, and analyzed from seventy five semi-structured interviews of leaders/staff. The analysis focused on the eight core EHR functionalities as identified by the IOM. Principal findings: Out-of-the-box, none of the EHRs studied strongly supported the provision of guideline based care to individual patients or the management of populations of patients. Extensive EHR modification was needed, with some EHRs requiring more work. Challenges were most acutely felt with templates, interfaces, decision support, and reporting functionalities. Limitations were found less often in administrative processes and within practice messaging. Though EHR functionalities greatly improved based on network and CHC development efforts, focus on quality improvement activities was diminished by the consumption of scarce resources to fix poorly functioning software. Conclusions: Given that EHR adoption rates will continue to increase it should be emphasized that successful QI efforts are difficult to achieve with the current state of the technology, especially for smaller practices. So far the onus of improving the functionalities for use in QI efforts has primarily been left to the EHR adopters, who generally lack the resources to develop the software. Policy needs to take this into account and fund not only EHR implementation, but also ensure great improvements are made to core functionalities. [The dissertation citations contained here are published with the permission of ProQuest LLC. Further reproduction is prohibited without permission. Copies of dissertations may be obtained by Telephone (800) 1-800-521-0600. Web page: http://www.proquest.com/en-US/products/dissertations/individuals.shtml.]