The government system for providing health care to veterans received national attention in 2008 when Barack Obama first ran for president. In a campaign document outlining his plans for improving the lives of veterans, Obama said he would make the U.S. Department of Veterans Affairs a leader in national health reform.

The Veterans Health Administration, a division of Veterans Affairs, is the largest health care system in the United States, with 152 hospitals, 800 community-based outpatient clinics and 126 nursing-home-care units. It serves more than 8.3 million veterans each year. Even before Obama became president, it had undergone a decade-long transformation from an inefficient bureaucracy to a model for technological and science-based innovations in U.S. health care.

As a candidate in 2008, Obama said the department would need to make progress on four fronts to meet his definition of "national leader in health reform”:

• Improve electronic records interoperability;
• Expand effectiveness research;
• Promote wellness programs;
• Instill more accountability for performance and quality improvement initiatives.

We'll take each component, piece by piece.

Electronic records interoperability: We recently wrote about Obama's goal of a connected electronic network between Veterans Affairs and the military. This would allow former service members to request health care benefits with greater ease because their medical files -- showing qualifying disabilities incurred on duty, for instance -- would be immediately accessible to physicians and nurses outside the military.

Instead, what we have today is a comprehensive electronic health network at the Veterans Health Administration and a growing number of electronic pilot projects at the Veterans Benefits Administration. The biggest outstanding problem is a disjointed records system in the military, reputed to be clunky and subject to frequent crashing, which is separate from the one in Veterans Affairs.

However, plans are in place to install electronic records systems across the benefits administration by the end of 2013; also, military department heads have agreed to launch a unified veterans-military electronic health records system by 2017. Full interoperability might be far off -- the current schedule would exceed Obama's second term in office -- but we do see some progress.

Effectiveness research: Comparative effectiveness research usually refers to studying the relative impact of different medical approaches in treating the same condition. Two of the biggest domestic policy laws signed by Obama in his first two years -- the American Recovery and Reinvestment Act and the Affordable Care Act -- both encouraged comparative effectiveness research. The economic stimulus created a new council to coordinate and guide comparative effectiveness research across federal departments (including Veterans Affairs). We dug into the annual budgets for Veterans Affairs over the last four years and found more evidence of expansion: Health research services -- which focuses on effectiveness strategies --- received $76 million in President George W. Bush's final budget, whereas it received $88 million, $94 million and an estimated $98 million in Obama's first three budgets.

Wellness programs: The Veterans Health Administration maintains a website dedicated to promoting healthful living, including educational pages on nine topics such as diet, alcohol consumption, tobacco use and exercise. It also has a weight-management program called MOVE!, a pilot program for behavioral counseling by phone -- helping veterans to quit smoking, for example -- and another pilot program for diabetes prevention. We also found the 2011-2015 strategic plan for Veterans Affairs includes a department-wide, web-based wellness initiative for department employees.

Accountability for performance and quality improvement initiatives: By boosting comparative effectiveness research, the health administration should be favoring medical options based on science-based results -- which is a kind of quality improvement. In terms of improved accountability, we didn't find much. One exception was the early push by the White House for more transparency across the federal government, including a default position of openness on Freedom of Information Act requests. Paul Sullivan, a spokesman for the advocacy group Veterans for Common Sense, said Veterans Affairs had a mixed record of complying with public records requests under Obama, but its performance was a vast improvement from the previous eight years.

Did Veterans Affairs become a leader in national health reform? The question invites a degree of subjectivity that goes beyond facts. Critics could point to the benefit claims, often health care-related, that go unanswered within 125 days of filing, which have nearly doubled under Obama. Long wait times and a growing demand for disability services, including mental health care, have drawn frequent news coverage in the past few years.

On the other hand, we also found recent examples of the Veterans Health Administration being lauded in academic journals as a model or leader in health care, in part because of gains in electronic health information systems and comparative effectiveness research. Sullivan, of Veterans for Common Sense, noted other positive changes in veterans' health care under Obama, such as an expanded suicide prevention hotline and a modified budgeting process that allows for more predictable funding and fewer delays in providing medical services.

For our purposes, it's more important to note that the Veterans Health Administration made strides in all four sub-areas mentioned in Obama's campaign promise. We rate this a Promise Kept.