Health information exchanges represent one way of making medical information available to practitioners across institutional boundaries. One health information exchange in Memphis Tennessee has been operational since May of 2006 and provides information supporting care for over 1.2 million individuals. Creating such an exchange challenged traditional institutional boundaries, roles, and perceptions. Approaching these challenges required leadership, trust, sound policy, new forms of dialogue, and an incremental approach to technology. Early evidence suggests a positive impact on patient care and a change in the way providers interact with their patients and on another. Personal health records, consolidated EHR systems, and other alternative models promise to have similar impacts on the way in which providers and patients interact with one another.