A comprehensive system for translating basic biomedical research into useful and effectively implemented clinical diagnostic, preventive, and therapeutic practices is essential to the nation's health. The state of clinical and translational research (CTR) in the United States, however, has been characterized as fragmented, slow, expensive, and poorly coordinated. As part of its Roadmap Initiative, the National Institutes of Health instituted the Clinical and Translational Science Awards (CTSA), a sweeping and ambitious program designed to transform the conduct of biomedical research in the United States by speeding the translation of scientific discoveries into useful therapies and then developing methods to ensure that those therapies reach the patients who need them the most. The authors review the circumstances of the U.S. biomedical research enterprise that led to the creation of the CTSA and discuss the initial strategic plan of the CTSA, which was developed from the first three years of experience with the program and was designed to overcome organizational, methodological, and cultural barriers within and among research institutions. The authors also describe the challenges encountered during these efforts and discuss the promise of this vital national health care initiative, which is essential to creating a pipeline for the scientific workforce needed to conduct research that will, in turn, provide a rational evidence base for better health in the United States.