Healthcare in the United States is in transition. Healthcare delivery organizations are undergoing drastic changes in how they care for people. These organizations range from small private physician offices to huge multisystem, multistate organizations. Whether large or small they share the need to manage change. Issues driving these changes include the need to increase safety of care and improve patient outcomes, proposals for changes in payment models, new legislation and regulatory agency rules regarding the use of electronic health records. The following case study is an example of an attempt to structure an alliance between two independent systems utilizing a single instance of an electronic health record. Names of the health systems are changed. I will discuss difficulties with this attempt, with emphasis on governance. I will seek methods for possible improvement through literature search and asking for expert opinions. Suggestions for other institutions starting this journey will be made.