Governance is one of the most challenging aspects of health information exchange (HIE). Effective governance cannot be imposed; it must be accepted by all stakeholders involved in HIE. Governance begins with the establishment of a governing body with broad representation drawn from stakeholders to facilitate consensus regarding data access and use. Data sharing agreements among the stakeholders enforce data access and use policies, forming a governance framework. This framework is essential to define what data will be shared, how it will be shared, to whom it will be shared, and when it will be shared. A governance framework promotes trust, supports additional stakeholders and approved use cases, and provides flexibility to adapt to a changing environment. This chapter outlines the core components of an effective governance framework and discusses the challenges to building and sustaining governance for HIE.