Indeed, HIEs may be developed for several different purposes, each of which makes its own distinct demands on design and implementation. The goal of sharing data for quality improvement (QI) has shaped the foundation for collaborative data-sharing in the United States over the last 10–15 years, and experiences of QI collaboratives have taught us much of what we know about successful HIE endeavors. The more recent campaign to share clinical data for direct patient care through the promotion of HIEs must build on the same foundation and face the same basic technological, human, usability, managerial and political risks as outlined by Sicotte and Pare [19]. In fact, the complexity of clinical HIE increases exponentially with the technical requirements of real-time round-theclock data-sharing capabilities, as well as the market-related challenges of sharing data among competing organizations