One interesting problem with health information exchanges (HIE) starts with the implied promise in the name itself. There is little to no focus on actual information exchange; rather, most HIEs are about consolidating information and channeling access to that information. Yet healthcare communities have a real need for an efficient means of exchanging data. Many HIE efforts start with the goal of sharing patient information across the community -- anywhere, anytime. In order for HIEs to be effective, it is important to realize that starting with a big bang approach or one that requires significant agreement across the community should be avoided. By shifting the initial focus from aggregating patient information to improving existing workflows, HIEs could leverage labor reduction as the business driver needed to financially support the HIE. Success depends not on waiting for broad standards and choosing the anointed technology but rather, on identifying existing pain points, using the HIE to deliver value by reducing the pain, then expanding the system across the community in a natural, incremental fashion.