Who Owns the Referral

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This issue is the companion to "The Day a Doctor Said Yes." The public piece follows a VA referral through seven steps, walks the six scheduling fixes since 2000 that each repaired one of them, and argues that the pathway between VA's two delivery systems has no named owner, no public clock, and no closed loop. This brief reads the same seven steps as a buying map, works the scheduling BPA VA signed on September 29 under the IHT 2.0 vehicle, lays out the External Provider Scheduling program record a proposal can cite, sets the standards stack beside it, and maps the bills and the AI inventory lines that would change the requirement.

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1. The picture at a glance

Field	Detail
The trip	Seven steps from consult entry to record return, with documented failures at triage (103 of 129 facility officials found the Referral Coordination Initiative challenging), authorization ("can take up to 14 days"), acceptance (673 of 20,463 sampled referrals with a usable acceptance date), appointment (5 of 133 systems met the seven-day mental health standard), and return (33 percent of behavioral health referrals without an initial-visit record) [CC1][CC2][CC3][CC4][CC5]
Scale	82.1 million direct care and 60.0 million community care appointments in FY2025; $23.0 billion paid to community providers in 2025; just over 14 million referrals in FY2024 through May 2025; 1.4 million providers in the community care directory [CC6][CC7][CC8]
Systems of record	VistA scheduling under Integrated Scheduling Solution through 2029; the Oracle Health module at 13 hospitals live in 2026 with 26 planned for 2027; EPS for community booking at every facility; the referral and authorization system for consults; VA officials to GAO, June 2026: the department "has not yet determined how the modernized and updated products used for scheduling will interface and be used to pull and combine the data" [CC9][CC10][CC11][CC4]
The September buy	BPA 36C10X26N0178 under IHT 2.0 IDIQ 36C10X25D0017, signed September 29, 2026, performance September 30, 2026 through September 29, 2031; solicitation 36C10X26R0052, SDVOSB set-aside, seven offers, SAC Frederick; "the ordering framework for VA Enterprise Scheduling Modernization, including interoperability, implementation, training, activation, adoption, sustainment, and support across the VA ($30M value may increase over time)"; six orders placed September 30: one for each of VISNs 1 through 5 at $3,593,765.20 and one enterprise order at $1,396,886.80, $19,365,712.80 in all [CC12][CC13]
Standards	HL7 SMART Scheduling Links, trial use (availability); IHE 360X (closed-loop referral); TEFCA (71,000+ sites); CMS-0057-F prior authorization decision deadlines in force since January 1, 2026, with APIs due January 2027 [CC14][CC15][CC16][CC17]
Congress	H.R. 3482 (EPS nationwide) passed the House by voice vote May 19, 2026; SCHEDULES Act S. 4229 and H.R. 8199 in committee; H.R. 740 ordered reported July 23, 2025; H.R. 9237 and S. 4744, the House and Senate Take Care of America's Veterans Act [CC18][CC19][CC20][CC21][CC22]
Dates	CCN Next Gen: four IDVs signed August 31, 2026 (Optum, Wellpoint, TriWest, Humana), performance January 1, 2027 through December 31, 2036; first 2027 Oracle wave in January at four Wisconsin and Michigan sites; Cleland-Dole sec. 122 wait-information plan was to be implemented by December 29, 2025 [CC23][CC10][CC24]

Confidence: High on the award records from USAspending and on the GAO, OIG, and hearing documents cited. Medium on program performance metrics, which VA and the vendor stated in testimony and which GAO has not audited. Strong inference on the VISN numbering in the September orders. Analytical on the market reads.

The lead finding for a capture team: the September BPA buys adoption. The technology award for External Provider Scheduling dates to September 2023, and the new agreement's own description is interoperability, implementation, training, activation, adoption, and sustainment. The six funded orders cover every network in VA's new five-VISN structure plus an enterprise order, $19.4 million in the first year against a stated $30 million value the record says may increase. Every documented failure in the pathway sits at a seam between two systems, VA has told GAO it has not yet determined how its scheduling products will interface, and the requirement for the seams is being written at CMS and in Congress before VA writes it for itself. The adoption lane is closed for the term of the BPA. The integration, data, and clock lanes are open, and whoever writes the architecture writes the next five years of orders.

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2. The pathway as a buying map

Confidence: High on the gaps, each tied to a GAO, OIG, or VA document. Medium on the system-of-record column, because VA has not published a target architecture, which is itself GAO's finding. Analytical on the capture column.

Step	System of record today	Owner	Documented gap	What gets bought
1. Consult entered	VistA/CPRS at most sites; Oracle Health at 13 hospitals	Clinician; facility	In a rheumatology study, the specialist recommended primary care management or another referral for 41 percent of e-consults; a VHA cardiology clinic triaged about 60 percent of consults to e-consult and cut median wait from 24 to 13 days; the model is unevenly used [CC25]	Clinical decision support, e-consult workflow, specialty triage tooling
2. Triage and route	Referral Coordination Teams under VHA Directive 1232	Office of Integrated Veteran Care (policy); facilities (execution)	103 of 129 facility officials called RCI challenging; implementation inconsistent [CC1]	Standard work, training, RCT staffing models, triage analytics
3. Authorize	HealthShare Referral Manager (HSRM), "VA's secure, web-based system for managing referrals and authorizations" [CC39]	IVC; facility community care staff	"Can take up to 14 days" per VA guidance; no public decision deadline; timeframes in an SOP "not available to the public" [CC2][CC26]	Decision-deadline analytics; eligibility automation; the CMS-0057-F pattern
4. Find a slot	EPS for community; VSE/ISS and the Oracle module for direct care	IVC (EPS); OIT and EHRM (direct)	No plan for how the scheduling products interface, by VA's own account to GAO; nine steps to book; 33 days by traditional means against 25 through EPS [CC4][CC8]	Integration, deployment, adoption (the September BPA)
5. Provider accepts	Telephone, fax, secure email; EPS booking where live	Facility; community provider	673 of 20,463 sampled referrals with a usable acceptance date [CC3]	Closed-loop messaging (360X), status capture, the clock
6. Appointment occurs	Community Care Network contractor networks; VA schedules through the local facility "with support, as needed" from the contractor [CC40]	TPAs under CCN; IVC oversight	5 of 133 systems met the seven-day mental health standard; network adequacy measured through the TPAs on standards VA says are unrelated to MISSION Act standards [CC5][CC8]	Network adequacy analytics; CCN Next Gen performance terms
7. Record returns	Varies by provider; VA told the House in May 2025 it does "not collect national-level data on document return at this point" [CC8]	Facility; community provider	33 percent of behavioral health referrals without an initial-visit record [CC4]	Records retrieval (VA-25-2660), TEFCA exchange, document AI
Across all seven	None	None named in public documents	VA officials to GAO: the department has not yet determined how the scheduling products will interface or how their data will be combined [CC4]	Target architecture, integration layer, a referral system of record, public reporting

Three reads. First, the only step with a dedicated buy this fiscal year is step four, and the BPA's scope words are adoption words. Second, steps five and seven are where the data does not exist, and a bidder who can show acceptance capture and record return as messages, with the acceptance date as a field in the record, is answering GAO's finding with a deliverable. Third, the row that says "None" is the market. VA's June testimony describes integrated scheduling pilots, GAO's June statement describes no architecture, and the party that writes the architecture sets the shape of every order that follows.

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3. The September scheduling BPA

Confidence: High on the award record, which USAspending carries in full. Strong inference on the VISN numbering. Analytical on the reads.

Item	Record
Vehicle	VHA Integrated Healthcare Transformation 2.0, IDIQ 36C10X25D0017: a ten-year multiple-award IDIQ with nine SDVOSB prime contractors per the August 26, 2025 SAM.gov award notice; the $14 billion ceiling and the four functional categories (health system transformation and innovation, implementation and operations support, healthcare business enabling services, health informatics) rest on trade reporting [CC27][CC28]
BPA	36C10X26N0178, signed September 29, 2026; performance September 30, 2026 through September 29, 2031, potential end September 29, 2032; solicitation 36C10X26R0052, SDVOSB set-aside, seven offers, Strategic Acquisition Center Frederick; description: "RFO FAR 16.5 BPA established as the ordering framework for VA Enterprise Scheduling Modernization, including interoperability, implementation, training, activation, adoption, sustainment, and support across the VA ($30M value may increase over time)" [CC12]
Orders, September 30, 2026	36C10X26N0209 (VISN 1), 36C10X26N0211 (VISN 2), 36C10X26N0212 (VISN 3), 36C10X26N0213 (VISN 4), 36C10X26N0214 (VISN 5), $3,593,765.20 each, through September 29, 2027, "to support the deployment of External Provider Scheduling integrated scheduling throughout the VHA," including facility coordination and enterprise communication; plus enterprise order 36C10X26N0204 at $1,396,886.80; $19,365,712.80 obligated in all [CC12]
Awardee	Agile4Vets LLC, an all-SDVOSB joint venture and one of the nine IHT 2.0 holders, per the award record and the company's own site [CC12][CC28]
Which networks	The orders run VISN 1 through 5 and no further. Legacy VISN 3 was integrated into VISN 2 in October 2015, VA's VISN page now says the department "comprises 5 Veterans Integrated Service Networks," and VA's EHR deployment schedule already uses the new numbering (VISN 3 from Ohio and Indiana to the Dakotas, VISN 4 Nebraska and Missouri, VISN 5 Washington, Oregon, Idaho, and Alaska). My read is that these are RISE's five networks, which makes the first year enterprise-wide; confirm with the contracting office before stating it as fact [CC29][CC38]
Technology vendor of record	WellHive, whose president testified to the House in May 2025 that the External Provider Scheduling contract was competitively awarded in September 2023; the company reports FedRAMP High authorization and the VA FAQ reports 150+ integrations [CC8][CC11]

Four reads. First, the scope language is a services scope. Interoperability, implementation, training, activation, adoption, sustainment, support: six of the seven words describe people and change management, and the seventh describes the seam. The agreement sits under a services IDIQ whose categories are implementation and operations support and health informatics, and the holder is a services joint venture. Second, the first year is already national. Five network orders of identical size plus an enterprise order, $19.4 million against a stated $30 million value, leaves about $10.6 million for years two through five unless the value rises, and the record says in its own description that it may. The shape to expect is a second-year obligation that either tops up the ceiling or converts the agreement into a larger follow-on. Third, a BPA establishes one ordering relationship, so the adoption lane under IHT 2.0 has narrowed to the holder and its team for the life of the agreement; seven offers competed for it, and the other eight IHT 2.0 holders now compete for the adjacent orders, which are the integration and data work in section 2. Fourth, the order descriptions say "External Provider Scheduling integrated scheduling," which reads as the Charleston and Atlanta pilots VA described in June, direct care and community care appointments "on the same platform," moving from pilot to deployment in every network at once. If that reading holds, the BPA is the vehicle through which direct care scheduling begins to run outside the EHR module, and the 2027 Oracle calendar, 26 hospitals across those same networks, is the constraint the deployment team will work around.

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4. External Provider Scheduling as a program record

Confidence: High on dates from the May 2025 hearing record, VA releases, and congressional releases. Medium on performance metrics, which VA and the vendor stated and GAO has not audited. Secondary on the October 2026 Epic connection.

Date	Event	Source
2020	Pilot launched at the Orlando VA Medical Center, later expanded to Columbia, South Carolina	[CC8]
December 2021	VA's written statement counts provider onboarding "since the pilot began in December 2021"; the vendor's testimony dates the pilot to 2020 in Orlando	[CC8]
September 2023	Competitive award of the External Provider Scheduling contract	[CC8]
2024	VA paused provider recruitment, deactivated live sites, and canceled nationwide expansion plans; VA's 2025 written statement describes a pause by the prior administration, and the subcommittee chairman called the budget shortfalls cited fake	[CC8]
October 2024	16 sites live	[CC8]
May 1, 2025	36 medical centers live (oral testimony; the written statement says 34 as of April 18), 18 more scheduled by the end of FY2025; 6,000+ provider services across 62 specialties (written: 5,200+ across 60+); a 30-minute initial scheduler training	[CC8]
2025	Vendor reports FedRAMP High authorization complete and a security assessment under VA review, with referral packet integration to follow approval	[CC8]
Late 2025	EPS implemented at all VA facilities	[CC30]
March 9, 2026	VA announces EPS at all facilities since late 2025, 27,000 community providers across 78 specialties, and a goal of thousands more in 2026	[CC30]
April 23, 2026	AMA guidance to community physicians: EPS "only aids with the initial appointment, not a complete community care integration solution"	[CC31]
May 19, 2026	H.R. 3482 passes the House by voice vote under suspension; referred to Senate VA May 20	[CC18]
June 12, 2026	Technology Modernization subcommittee hearing; VA testimony that integrated scheduling pilots begun in January 2026 at Charleston and Atlanta show direct and community appointments "on the same platform," with over 29,000 community providers and more than 150,000 EPS appointments as of May 2026; GAO statement that VA has not yet determined how its scheduling products will interface	[CC32][CC4]
August 2026	VA provider FAQ: 150+ integrations with community EHR and scheduling systems	[CC11]
September 29 and 30, 2026	Scheduling modernization BPA signed; six orders placed the next day, one per VISN under the new structure plus an enterprise order	[CC12]
October 19, 2026	Epic newsroom: a VA-Epic connection lets VA staff book specialist appointments at Epic-based health systems through EPS	[CC33]

Performance claims on the record, all VA- or vendor-stated: seven minutes on average to schedule through EPS; up to four times scheduler productivity; traditional referrals averaging 33 days to schedule at live sites against 25 through EPS; more than 3,000 appointments in the month of the May 5, 2025 hearing, the most of any month to that date; active provider services growing 21 percent month over month and appointments up 121 percent in the first four months of 2025. [CC8] A proposal can cite these as VA's own numbers. It should not present them as audited.

Three limits belong in any solution narrative. EPS books the first appointment, and the AMA's wording is the cleanest statement of that boundary. [CC31] Onboarding is the long pole: Nebraska's two academic medical centers began onboarding in October 2024 and were still in process the following May, and one live site had two providers signed up while others had hundreds. [CC8] And as of May 2025 the referral packet still went by fax or secure email after the booking, pending the FedRAMP High integration; whether that integration is complete is not stated in the 2026 documents reviewed for this brief. [CC8]

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5. The standards stack

Confidence: High on the standards as published. Analytical on how VA would use them.

Standard	What it does	Where it fits	Status
HL7 SMART Scheduling Links	Defines how a Slot Publisher exposes availability to a Slot Discovery Client across EHRs	Step 4; the supply view without dependence on one vendor	Trial use, STU 1, version 1.0.0-ballot; the build page is not an authorized publication [CC14]
IHE 360X closed-loop referral	Carries a referral as transactions: request, accept or decline, appointment notification (optional), no-show, interim consultation, referral outcome; built on HL7 v2, C-CDA, and Direct	Steps 5 and 7; the accept message as the acceptance date	IHE trial implementation profile; no published FHIR version found [CC15]
TEFCA	National exchange framework, 71,000+ connected sites	Step 7; the return path	Live [CC16]
CMS-0057-F	Seven-calendar-day standard and 72-hour expedited prior authorization decisions from January 1, 2026; Prior Authorization APIs from January 2027	Step 3; the decision-deadline pattern	In force for Medicare Advantage, Medicaid, and CHIP; VA not covered [CC17]
NHS England RTT rules suite	Clock start and stop rules across a referral, including a start on referral to a referral management service; no pauses permitted since October 2015	Across all steps; the public clock	NHS Constitution right, with standards set in the 2012 Standing Rules Regulations [CC34]

My read is that a team which writes its solution against these five documents is writing to the requirement before VA does. The SCHEDULES Act would compel a standard for the time between referral entry and appointment, with quarterly reporting and a facility ranking. [CC19] A clock that starts at consult entry and stops at the completed first visit, with veteran-requested delays recorded and reported instead of subtracted, is the NHS rules suite in VA's vocabulary, and a referral carried as 360X transactions produces the timestamps that clock needs. The integration work under the September BPA is where the first version of that gets built, whether or not anyone calls it a clock.

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6. The CCN lane and the wait-time duty

Confidence: High on the OIG and VA documents and on the CCN Next Gen award records in USAspending.

VA's acting deputy assistant under secretary for integrated veteran care told the House in May 2025 that network adequacy "is not measured by individual Community Care providers, it is done through the TPAs, who then have different standards not related to MISSION Act standards." [CC8] The inspector general's August 2026 mental health review recommended adjusting the community care contracts so the contractors can deliver timely care. [CC5] VA's February 2025 plan to Congress under section 122 of the 2022 Cleland-Dole Act, which required a plan for telling veterans the expected days to care with VA and community providers and implementation by December 29, 2025, said that community availability "is reliant on extensive communication with numerous community providers" and that "there is currently no immediate solution that provides Veterans with average wait times in the community," and pointed to EPS and a community care self-scheduling pilot as the routes it would build. [CC24] Whether EPS data now serves that duty is not stated in any VA document reviewed for this brief.

The next Community Care Network contracts, CCN Next Gen, are on the record in USAspending: four IDVs signed August 31, 2026 by the Strategic Acquisition Center Fredericksburg, to Optum Public Sector Solutions (36C10G26D0024), Wellpoint Federal Solutions (0022), TriWest Healthcare Alliance (0025), and Humana Government Business (0026), with performance January 1, 2027 through December 31, 2036 and nothing obligated yet. [CC23] If the performance terms carry acceptance-date reporting, appointment-occurrence timeliness, and record return as contractor obligations, the TPA becomes the party that produces the data VA cannot. If they do not, the gap GAO measured in 2024 persists through the next contract period by design, and the integration market for steps five through seven stays open.

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7. Congress: the clock by statute

Confidence: High on bill text and status as of October 26. None of these is enacted.

Bill	What it does	Status	Pathway tie
H.R. 3482, Veterans Community Care Scheduling Improvement Act	Mandates nationwide implementation of EPS	Passed the House by voice vote under suspension May 19, 2026; referred to Senate VA May 20 [CC18]	Codifies step 4
S. 4229 (Sen. Rick Scott, with Cruz and Ossoff) and H.R. 8199 (Rep. Scott Franklin, with Panetta), SCHEDULES Act of 2026	VA sets a standard for time between referral entry and appointment, publishes it in the Federal Register and on a VA website, reports quarterly, and publishes rankings for each facility	Introduced March 26 and April 6, 2026; in committee [CC19]	The public clock
H.R. 740, Veterans' ACCESS Act (Bost)	"Establishes in statute access standards" for community care	Ordered reported, amended, by voice vote July 23, 2025 [CC20]	Step 2; the cost trade-off
H.R. 9237, Take Care of America's Veterans Act (House), sec. 601	Codifies community care eligibility standards: 20 days and 30 minutes for primary and mental health care, 28 days and 60 minutes for specialty care	House proceedings postponed July 16, 2026 [CC21]	Step 2
S. 4744, Take Care of America's Veterans Act (Senate, Moran)	Codifies Veterans Community Care Program eligibility standards; sec. 407 requires electronic scheduling of community care appointments within two years; sec. 318 requires a scheduling-improvement plan	Introduced June 10, 2026; Senate Calendar No. 433 [CC22]	A vehicle for a decision deadline at step 3; the text as introduced carries none
Cleland-Dole Act of 2022, Division U, sec. 122	A plan for informing veterans of expected wait times with VA and community providers	Enacted December 2022; implementation due December 29, 2025 [CC24]	Step 4 supply view

Two reads. A standard set by statute is a requirement with a date, and the SCHEDULES Act's quarterly report and facility ranking would create a reporting product VA does not have today. H.R. 3482 would make EPS a statutory program, which protects the adoption lane from the kind of pause VA imposed in 2024 and makes the BPA's five-year horizon more credible than the program's own history suggests.

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8. The AI inventory lines that touch the trip

Confidence: High on the inventory entries as listed in April 2026. Verify current deployment status.

Use case	What it does	Step	Status as listed
VA-24-421, Patient Care Services Integration Platform	Summarizes a veteran's history from VistA/CPRS, Cerner, and outside records in PDF; estimates time to appointment in direct and community care; vendor-purchased generative AI	1, 3, 4	Pilot, high-impact [CC35]
VA-25-2660, Community Care Records Retrieval	Agentic retrieval of community care records	7	Pre-deployment, high-impact [CC35]
VA-25-817, CCN Provider Directory	Predictive machine learning over 1.5 million-plus providers and 9 million-plus provider services	6	Pre-deployment, high-impact [CC35]

The parallel on the Department of War side is worth a line for teams that work both departments. GAO's October 16 report on service member records, GAO-27-107784, recommends that the Assistant Secretary for Health Affairs and the DHA Director include the health records framework in DHA's health informatics business-function study, "such as consolidating databases or using artificial intelligence," because DHA still assembles a record from MHS GENESIS, AHLTA, Essentris, HAIMS, and paper, and "providers generally must rely on multiple systems to obtain a complete set of records." [CC36] Two departments, the same recommendation, and the same limit: an overlay reads only the status the source records.

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9. The counterargument, stated fairly

Confidence: The strongest case against the reads above, and parts of it are right.

VA is building the architecture; it is in the pilots. The June testimony describes integrated scheduling pilots, the September BPA funds "integrated scheduling" deployment, and the Epic connection extends supply visibility to the largest civilian systems. [CC32][CC12][CC33] The architecture may exist inside the program and simply be unpublished. GAO's statement reports what VA officials told it, that the department has not yet determined how the products will interface, and an undocumented architecture is a risk to price into a bid, and a reason to ask for the document in the next RFI, before assuming the market is open.

The TPAs already own steps five through seven. Under CCN, the contractors manage the networks and support scheduling as needed. If CCN Next Gen carries the data obligations, the integration market shrinks to the seam between the TPA and VA. That seam is still a seam, and GAO's three percent was measured with the TPAs in place.

Capacity, again. VHA lost 783 physicians in the first eleven months of FY2026, which means more referrals outward regardless of the pathway, and a faster pathway raises the $23 billion community bill; CBO scores eligibility changes in the billions. [CC37][CC7] A bidder who promises wait-time reduction is promising what the pathway alone cannot deliver. A bidder who promises visibility is promising what the documents say is missing.

The small-business field is set. With the BPA in place, the adoption work for the life of the agreement runs through one holder. The counter is that the orders are a year long and the ceiling is a framework, and VA has shown with EPS itself that it will pause, deactivate, and restart a program inside a contract term. [CC8]

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10. What to do in the next ninety days

Confidence: Analytical.

1. Pull the BPA and the six orders from SAM.gov. The award record confirms the $30 million value, the SDVOSB set-aside, seven offers, and SAC Frederick. What it does not say is whether "VISN 1 through 5" are RISE's five networks; the evidence says yes, and the contracting office can confirm it in one call. Then read the orders' "integrated scheduling" language against the June pilots. [CC12][CC29][CC38]

2. Map the other eight IHT 2.0 holders to the adjacent work. Integration, data, architecture, and analytics orders under the implementation and health informatics categories are the open lanes; the adoption lane is closed for the BPA's term. [CC27]

3. Write the acceptance date as a deliverable. Any solution narrative for steps five and seven should show the referral as 360X messages with timestamps and should cite GAO-24-105308 by number. [CC3][CC15]

4. Price to the CMS pattern. A seven-day standard and a 72-hour urgent standard for the authorization step are the numbers a congressional staffer will recognize, and the Prior Authorization API deadline in January 2027 is the technical precedent. [CC17]

5. Read CCN Next Gen before January 1. The four IDVs are signed and on USAspending; pull the performance work statement and look for acceptance, occurrence, and record-return obligations. The lane is either in the TPA contract or it is open. [CC23]

6. Track three bills. H.R. 3482 in the Senate, the SCHEDULES Act in both committees, and any lame-duck vehicle carrying access standards. [CC18][CC19]

7. Build around the 2027 Oracle calendar. Four Wisconsin and Michigan sites go live in January and 22 more follow. Deployment work in networks that cross those waves will be scheduled around them, and a team with go-live capacity planning on its record has a story to tell. [CC10]

8. Hold the records-return lane for the AI inventory. VA-25-2660 is pre-deployment, GAO's October report makes the same ask of DHA, and TEFCA is the exchange both would use. One capability, two departments. [CC35][CC36][CC16]

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Mary

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Sources

[CC1] U.S. Government Accountability Office, GAO-25-108101. Source for: 103 of 129 facility officials describing the Referral Coordination Initiative as challenging; 27 recommendations with nine implemented as of February 2025; no standard for when community appointments must occur. https://www.gao.gov/products/gao-25-108101

[CC2] Department of Veterans Affairs, "How to get community care referrals and schedule appointments," VA.gov. Source for: "This part of the process can take up to 14 days." https://www.va.gov/resources/how-to-get-community-care-referrals-and-schedule-appointments/

[CC3] U.S. Government Accountability Office, GAO-24-105308. Source for: VA's inability to produce the referral acceptance date and 673 of 20,463 sampled referrals with usable data. https://www.gao.gov/products/gao-24-105308

[CC4] U.S. Government Accountability Office, GAO-26-109213, statement of Chelsea Harris before the House Committee on Veterans' Affairs, Subcommittee on Technology Modernization, June 12, 2026. Source for: the quoted statement, reported by GAO as what VA officials told it, that the department "has not yet determined how the modernized and updated products used for scheduling will interface and be used to pull and combine the data into a comprehensive report" (p. 12), and 118,373 of 357,299 behavioral health referrals, 33 percent, without initial-visit records, FY2021 through FY2023 (p. 13). https://docs.house.gov/meetings/VR/VR11/20260612/119376/HHRG-119-VR11-Wstate-HarrisC-20260612.pdf

[CC5] Department of Veterans Affairs Office of Inspector General, "Review of Timeliness of Mental Health Community Care Appointments," 25-03623-147, August 10, 2026. Source for: five of 133 systems meeting the seven-day standard and the recommendation on community care contracts. https://www.vaoig.gov/sites/default/files/reports/2026-08/vaoig-25-03623-147-final.pdf

[CC6] Department of Veterans Affairs, "Following major reforms, over 300K new Veterans enroll in VA health care in 2026," October 21, 2026. Source for: 82,083,918 direct care and 59,989,662 community care appointments in FY2025. https://news.va.gov/press-room/following-major-reforms-over-300k-new-veterans-enroll-in-va-healthcare-in-2026/

[CC7] Congressional Budget Office, publication 61960. Source for: $23.0 billion in community provider payments in 2025 and the scoring of eligibility changes. https://www.cbo.gov/publication/61960

[CC8] U.S. House of Representatives, Committee on Veterans' Affairs, Subcommittee on Technology Modernization, "Improving Access to External VA Care Through Enhanced Scheduling Technology," May 5, 2025, Serial No. 119-19. Source for: the EPS timeline, the September 2023 award, the 2024 pause, site counts, provider counts, performance claims, the 14 million referrals, the 1.4 million-provider directory, the network adequacy quotation, the Nebraska onboarding account, the FedRAMP High status, and the referral packet transmission method. https://congress.gov/119/chrg/CHRG-119hhrg61152/CHRG-119hhrg61152.pdf

[CC9] U.S. Government Accountability Office, GAO-25-106851. Source for: the Integrated Scheduling Solution on VistA through 2029. https://files.gao.gov/reports/GAO-25-106851/index.html

[CC10] Department of Veterans Affairs, Electronic Health Record Modernization, "VA deploys electronic health record system to hospitals in Cleveland, Anchorage," October 26, 2026. Source for: 13 hospitals in 2026, 26 in 2027, and the January 2027 sites. https://digital.va.gov/ehr-modernization/news-releases/va-deploys-electronic-health-record-system-to-hospitals-in-cleveland-anchorage/

[CC11] Department of Veterans Affairs, Veterans Health Administration, "FAQ for EPS Providers," August 2026. Source for: 150+ integrations. https://department.va.gov/vha/wp-content/uploads/sites/65/2026/08/FAQ-for-EPS-Providers-VA-Styled.pdf

[CC12] USAspending.gov, award record for BPA 36C10X26N0178 under IDIQ 36C10X25D0017. Source for: signature date September 29, 2026; performance September 30, 2026 through September 29, 2031 with potential end September 29, 2032; solicitation 36C10X26R0052; SDVOSB set-aside; seven offers; Strategic Acquisition Center Frederick; the quoted description including "($30M value may increase over time)"; the awardee; and the six orders of September 30, 2026 (36C10X26N0209, 0211, 0212, 0213, 0214 at $3,593,765.20 each for VISNs 1 through 5, and enterprise order 36C10X26N0204 at $1,396,886.80), $19,365,712.80 in all. https://api.usaspending.gov/api/v2/awards/CONT_AWD_36C10X26N0178_3600_36C10X25D0017_3600/

[CC13] G2X, "Agile4Vets wins VA Enterprise Scheduling Modernization task," September 30, 2026. Aggregator, corroborated by the award record on the $30 million value and the ordering office. https://g2x.com/app/health/posts/va-awards-abd-modern-claims-processing-services-contract-to-pgt

[CC14] HL7, SMART Scheduling Links, version 1.0.0-ballot, STU 1, trial use, continuous build; the page states it is not an authorized publication. https://build.fhir.org/ig/HL7/smart-scheduling-links/en/specification.html

[CC15] IHE International, Patient Care Coordination Technical Framework Supplement, "360 Exchange Closed Loop Referral (360X)," Trial Implementation, and CMS, ACCESS model interoperability webinar slides, 2026. https://www.ihe.net/uploadedFiles/Documents/PCC/IHE_PCC_Suppl_360X_Rev1.1_TI_2017-09-08.pdf and https://www.cms.gov/priorities/innovation/files/access-interop-webinar-slides.pdf

[CC16] Assistant Secretary for Technology Policy / Office of the National Coordinator, "Data Liquidity, Affordability, and Access: The History and Growth of TEFCA," updated June 5, 2026. Source for: "over 71,000 sites or organizations are participating in TEFCA through 11 QHINs." https://healthit.gov/resources/data-liquidity-affordability-and-access-the-history-growth-of-tefca/

[CC17] Centers for Medicare & Medicaid Services, CMS-0057-F frequently asked questions and final rule presentation. https://www.cms.gov/initiatives/burden-reduction/overview/interoperability/frequently-asked-questions/improving-prior-authorization-processes and https://www.cms.gov/files/document/cms-interoperability-prior-authorization-final-rule-presentation-3-26-24.pdf

[CC18] Congress.gov, H.R. 3482, Veterans Community Care Scheduling Improvement Act, 119th Congress. Source for: passage under suspension by voice vote May 19, 2026, and referral to Senate VA May 20, 2026. https://www.congress.gov/bill/119th-congress/house-bill/3482/all-info

[CC19] S. 4229 and H.R. 8199, SCHEDULES Act of 2026, and Office of Sen. Ted Cruz, "Sens. Cruz, Scott, Ossoff Lead Bipartisan Effort Ensuring Veterans Receive Timely Access to Health Care." https://www.congress.gov/bill/119th-congress/senate-bill/4229/all-info and https://www.congress.gov/bill/119th-congress/house-bill/8199 and https://www.cruz.senate.gov/newsroom/press-releases/sens-cruz-scott-ossoff-lead-bipartisan-effort-ensuring-veterans-receive-timely-access-to-health-care

[CC20] H.R. 740, Veterans' ACCESS Act, 119th Congress. Source for: "Ordered to be Reported (Amended) by Voice Vote," July 23, 2025, and the CRS summary "Establishes in statute access standards." https://www.congress.gov/bill/119th-congress/house-bill/740/all-info

[CC21] H.R. 9237, Take Care of America's Veterans Act, 119th Congress, section 601, "Codification of requirements for eligibility standards for access to community care." Source for: the 20-day and 30-minute standards for primary and mental health care and 28-day and 60-minute standards for specialty care, and House proceedings postponed July 16, 2026. https://www.congress.gov/bill/119th-congress/house-bill/9237/text

[CC22] S. 4744, Take Care of America's Veterans Act, 119th Congress, introduced June 10, 2026, Calendar No. 433. Source for: the codification of Veterans Community Care Program eligibility standards, sec. 407 on electronic scheduling, and sec. 318 on a scheduling-improvement plan. https://www.congress.gov/bill/119th-congress/senate-bill/4744/all-info and https://www.congress.gov/bill/119th-congress/senate-bill/4744/text

[CC23] USAspending.gov, award records for CCN Next Gen IDVs 36C10G26D0024 (Optum Public Sector Solutions), 36C10G26D0022 (Wellpoint Federal Solutions), 36C10G26D0025 (TriWest Healthcare Alliance), and 36C10G26D0026 (Humana Government Business), signed August 31, 2026 by the Strategic Acquisition Center Fredericksburg, performance January 1, 2027 through December 31, 2036. https://api.usaspending.gov/api/v2/awards/CONT_IDV_36C10G26D0024_3600/

[CC24] Department of Veterans Affairs, "Plan Regarding Informing Veterans of Expected Wait Times for Appointments of Care," report to Congress under section 122 of Division U of the Joseph Maxwell Cleland and Robert Joseph Dole Memorial Veterans Benefits and Health Care Improvement Act of 2022, February 2025. Source for: the section 122(a) plan requirement and section 122(b) implementation deadline of December 29, 2025 (p. 1); "is reliant on extensive communication with numerous community providers" and "there is currently no immediate solution that provides Veterans with average wait times in the community" (p. 2); and EPS and a self-scheduling pilot as planned routes (pp. 4-5). https://www.govinfo.gov/content/pkg/CMR-VA1-00199314/pdf/CMR-VA1-00199314.pdf

[CC25] Malcolm et al., Journal of Clinical Rheumatology, 2022, as listed by VA Health Services Research and Development, citation 155942 (rheumatologists "recommended management in primary care or referral to another specialty for 41% of eConsults"), and American Journal of Managed Care, 2019, PubMed 31120719 (VHA cardiology clinic, about 60 percent of consults triaged to e-consult, median wait from 24 to 13 days). https://www.hsrd.research.va.gov/research/citations/abstract.cfm?Identifier=155942 and https://pubmed.ncbi.nlm.nih.gov/31120719/

[CC26] Veterans Health Administration, Directive 1232, November 22, 2024. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=12082

[CC27] SAM.gov, VHA IHT 2.0 award notice, August 26, 2025 ("a 10-year, multiple-award IDIQ Contract with a pool of [SDVOSB] prime contractors"; nine contracts), and Nextgov, "Veterans Affairs chooses 9 for $14B health care transformation recompete," August 2025, with GovConWire, 2025 (secondary, for the $14 billion ceiling and the four functional categories). https://sam.gov/workspace/contract/opp/d43d3d6fe5c04075a6a685520fa2b906/view and https://www.nextgov.com/acquisition/2025/08/veterans-affairs-chooses-9-14b-health-care-transformation-recompete/407699/ and https://www.govconwire.com/articles/va-vha-iht-2-contract-award-sdvosb

[CC28] SAM.gov IHT 2.0 award notice (naming AGILE4VETS LLC as an awardee) and Agile4Vets LLC, company site (for the all-SDVOSB joint venture description and contract number 36C10X25D0017). https://sam.gov/workspace/contract/opp/d43d3d6fe5c04075a6a685520fa2b906/view and https://www.agile4vets.com/

[CC29] Department of Veterans Affairs, RISE, and VA's Veterans Integrated Service Networks page, which states the department "comprises 5 Veterans Integrated Service Networks"; VA OIG 21-00240-158, p. 5, for the October 2015 integration of VISN 3 into VISN 2. https://digital.va.gov/rise/ and https://department.va.gov/integrated-service-networks/ and https://www.oversight.gov/sites/default/files/documents/reports/2022-05/VAOIG-21-00240-158.pdf

[CC30] Department of Veterans Affairs, "VA moves to speed up community care appointment scheduling," March 9, 2026. Source for: "EPS was implemented in all VA facilities by late 2025" and 27,000 participating community care providers across 78 medical specialties. https://news.va.gov/press-room/va-moves-to-speed-up-community-care-appointment-scheduling/

[CC31] American Medical Association, "Enterprise Patient Scheduling (EPS): What community physicians need to know about VA scheduling," April 23, 2026. https://www.ama-assn.org/public-health/population-health/enterprise-patient-scheduling-eps-what-community-physicians-need

[CC32] Department of Veterans Affairs, statement of Andrew Gradison, Senior Advisor to the Under Secretary for Health, before the House Committee on Veterans' Affairs, Subcommittee on Technology Modernization, June 12, 2026. Source for: integrated scheduling pilots at Charleston and Atlanta begun January 2026, "on the same platform" (pp. 1-2); over 29,000 community providers, more than 41,000 provider services, and more than 150,000 appointments as of May 2026 (p. 2). https://www.congress.gov/119/meeting/house/119376/witnesses/HHRG-119-VR11-Wstate-GradisonA-20260612.pdf

[CC33] Epic, "VA-Epic Connection Makes It Easier to Book Specialist Appointments for Veterans," newsroom, October 19, 2026, and HIT Consultant, "VA-Epic Connection Enables Direct Specialist Scheduling for Veterans," October 19, 2026 (secondary). https://www.epic.com/epic/newsroom/ and https://hitconsultant.net/2026/10/19/va-epic-connection-external-provider-scheduling-wellhive-veteran-specialist-appointments/

[CC34] NHS England, "Referral to treatment consultant-led waiting times rules suite," October 2022. Source for: Rule 1(b) clock start on referral to a referral management service; Rule 4 clock stops; "there is no provision to pause or suspend an RTT waiting time clock under any circumstances" since October 1, 2015; and the NHS Constitution right with standards in the 2012 Standing Rules Regulations. https://www.gov.uk/government/publications/right-to-start-consultant-led-treatment-within-18-weeks/referral-to-treatment-consultant-led-waiting-times-rules-suite-october-2022

[CC35] Department of Veterans Affairs, AI Use Case Inventory 2025, April 2026 update. Source for: VA-24-421, Patient Care Services Integration Platform (pilot); VA-25-2660, Community Care Records Retrieval (agentic AI, pre-deployment); VA-25-817, CCN Provider Directory (predictive ML, pre-deployment). https://department.va.gov/ai/wp-content/uploads/sites/26/2026/04/VA-AI-Use-Case-Inventory-2025-Web-Compliance-Updates.xlsx

[CC36] U.S. Government Accountability Office, "Service Member Records: DOD Needs to Address Improper and Delayed Releasing of Personnel and Health Information," GAO-27-107784, October 16, 2026, recommendation 5 and pp. 23-24. https://www.gao.gov/assets/gao-27-107784.pdf

[CC37] Department of Veterans Affairs, VA Workforce Dashboard, Issue 41, September 25, 2026, data through August 31, 2026. Source for: physicians from 28,340 to 27,557 in fiscal 2026 to date. https://department.va.gov/employees/wp-content/uploads/sites/63/2026/10/VA-Workforce-Dashboard-Issue-41.pdf

[CC38] Department of Veterans Affairs, Electronic Health Record Modernization, deployment schedule. Source for: the five-network numbering and the sites listed under VISN 3 (WI, MI, IL, ND, SD, MN, IA, OH, IN, and Fort Thomas, KY), VISN 4 (NE, MO), and VISN 5 (WA, OR, ID, and Anchorage, AK). https://digital.va.gov/ehr-modernization/ehr-deployment-schedule/

[CC39] Department of Veterans Affairs, Veterans Health Administration, community care, "Care coordination tools." Source for: "HealthShare Referral Manager (HSRM) is VA's secure, web-based system for managing referrals and authorizations." https://department.va.gov/vha/community-care/care-coordination/care-coordination-tools/

[CC40] Department of Veterans Affairs, Community Care Network fact sheet 26-04. Source for: "VA will directly schedule community care appointments for Veterans through the local facility, with support, as needed, from VA's contracted CCN TPA." https://www.va.gov/COMMUNITYCARE/docs/pubfiles/factsheets/FactSheet_26-04.pdf

Sources verified as of October 26, 2026.