This Arizona case study details the state’s efforts to establish electronic referral (eReferral) capacity between the Arizona Smokers’ Helpline (ASHLine) and El Rio Community Health Center. Facing initial obstacles with the state’s Health Information Exchange, the project team successfully implemented direct messaging for secure, bi-directional exchange of patient data using Consolidated-Clinical Document Architecture (C-CDA). While achieving two-way CCDA exchange, full eReferral integration was still in progress during the study period, with ongoing efforts to align workflows. Key lessons learned emphasized the necessity of consistent communication, prioritization, the significant technical effort required for integration, and the need for better documentation and resources for C-CDA and EHR implementation. Despite challenges, direct messaging emerged as a viable and cost-effective eReferral solution for Arizona, demonstrating the feasibility of electronic exchange and setting the stage for future scalability.