A recent New Yorker article by Atul Gawande skillfully draws an analogy between today’s health care crisis and the food crisis our country faced a century ago. Whereas the heath care system currently consumes about 17% of the U.S. economy, Americans spent more than 40% of their income on food at the turn of the last century. Like our current health care system, there existed a huge chasm between what science suggested could be achieved in improved quality and productivity and how farmers dispersed throughout the country were actually practicing.

Gawande describes how the federal government developed the agricultural extension program to bring the latest science to real-world practice. By finding practicing leaders in the community, developing pilot projects, providing implementation expertise and technical assistance, and continuously building on what was learned, these regional extension centers developed best practices that ultimately became embedded into U.S. farming practice. A century later, food consumes just 8% of household income.

Two recent and thoughtful critiques of Gawande’s argument appeared in the blogosphere—one from Alan Enthoven on the Health Affairs Blog and the other from Matthew Holt on The Health Care Blog—suggesting that Gawande made some critical errors in drawing this analogy. Notwithstanding some important issues raised by Enthoven and Holt, Gawande could have made the argument stronger if he had gone one step further.

In drawing his analogy, Gawande focuses exclusively on the pilot programs included in the health care reform legislation now being debated by Congress. Although Gawande is correct that these bills have critically important pilot and demonstration projects that have the potential to stimulate innovation and diffuse best practices, they are building on health care reform work the 111th Congress has already done. The critical piece missing from Gawande’s article is that Congress’s down payment on health care reform in the form of the American Recovery & Reinvestment Act. ARRA already has put in motion both the extension center model and the incentives to make it economically worthwhile for providers (in addition to other important infrastructure such as comparative effectiveness research).

Remember that the HITECH provisions (the portion of ARRA dealing with health information technology) not only tried to realign incentives by offering (in the neighborhood of) $35 billion for providers who become “meaningful users” of HIT. HITECH also included $2 billion of infrastructure support to promote the innovation, technical support and guidance necessary to stimulate that innovation.

And, very importantly, these are all linked together.  That is, ONC is crafting its extension centers, the associated HIT Research Center, the workforce programs, the health information exchange grants, the Beacon communities, and the SHARP innovation grants (and much more) to stimulate innovation and diffuse best practices in the meaningful use of HIT to improve health, health care delivery, and cost-efficiency. That cohesive, thoughtful approach helps pave the way for other important pilot and demonstration projects that will build on the progress made by ONC’s extension program.

In the coming weeks, we’ll be blogging about more specifics of our extension program efforts and how they will help guide us toward meaningful reforms of the delivery system.