This mixed methods multiple case study examines the knowledge, understanding, and awareness of 25 health board/facility oversight managers and 20 health professional association directors about privacy and security issues important to achieving health information exchange (HIE) in the state of Nebraska. Within case analyses revealed that health board/facility oversight managers were unaware of key elements of the federal agenda; their concerns about privacy encompassed broad definitions both of what constituted a "health record" and "regulations centeredness." Alternatively, health professional association leaders were keenly aware of national initiatives. Despite concerns about HIE, they supported information exchange believing that patient care quality and safety would improve. Cross-case analyses revealed a perceptual disconnect between board/facility oversight managers and professional association leaders; however, both favored HIE. Understanding state-level stakeholder perceptions helps us further understand our progress toward achieving the national health information interoperability goal. There is an ongoing need to assure adequate patient privacy protection. Licensure and facility boards at the state level are likely to have a major role in the assurance of patient protections through facility oversight and provider behavior. The need for these boards to take an active role in oversight of patient rights and protections is imminent. Similarly, professional associations are the major vehicles for post-graduate education of practicing health professionals. Their engagement is essential to maintaining health professions knowledge. States will need to understand and engage both of these key stakeholders to make substantial progress in moving the HIE agenda forward.