These incentives are now shaping current efforts by hospitals and physician practices to participate not only in EHR implementation, but also in HIE endeavors, and increasing numbers of HIEs are now appearing [10]. In the U.S., the number of HIEs operational in 2010 was 73, up from 57 in 2009 according to the eHealth Initiative [10], although the data exchanged still appear quite limited in scope [10,11], and many more efforts remain relegated to the planning stages. Progress in building HIEs has been slow, and these attempts commonly stall or fail [1,12–15]. The most significant challenge continues to be the development of a sustainable business model [10,12]. The difficulty in holding diverse stakeholders together, forming a collaborative governance system and gaining stability until achieving membership financing for the new organization, is formidable.