Many methods and criteria are available to assess aquatic ecosystems, and this review focuses on a set that demonstrates advancements from community analyses to methods spanning large spatial and temporal scales. Basic methods have been extended by incorporating taxa sensitivity to different forms of stress, adding measures linked to system function, synthesizing multiple faunal groups, integrating biological and physical attributes, spanning large spatial scales, and enabling simulations through time. These tools can be customized to meet the needs of a particular assessment and ecosystem. Two case studies are presented to show how new methods were applied at the ecosystem scale for achieving practical management goals. One case used an assessment of biotic structure to demonstrate how enhanced river flows can improve habitat conditions and restore a diverse fish fauna reflective of a healthy riverine ecosystem. In the second case, multitaxonomic integrity indicators were successful in distinguishing lake ecosystems that were disturbed, healthy, and in the process of restoration. Most methods strive to address the concept of biological integrity and assessment effectiveness often can be impeded by the lack of more specific ecosystem management objectives. Scientific and policy explorations are needed to define new ways for designating a healthy system so as to allow specification of precise quality criteria that will promote further development of ecosystem analysis tools.