Prediabetes and Type 2 Diabetes: Part One, Screening


This artifact provides patient-centered, evidence-based preventive health information to patients between the ages of 35-70 who are identified as overweight or obese to: 1) raise awareness that they may have one or more risk factor(s) for prediabetes or Type 2 diabetes, 2) provide educational materials that explain how overweight/obesity and other personal/family factors increase their risk, and 3) encourage them to talk to their primary care clinician about being screened for prediabetes and type 2 diabetes.

The artifact represents the first part of the U.S. Preventive Services Task Force (USPSTF) Prediabetes and Type 2 Diabetes: Screening recommendation.

Creation Date

Artifact Creation and Usage


This artifact was developed by MITRE software engineers and clinical informaticists, in collaboration with clinical subject matter experts and leaders from the USPSTF.

Additional information about MITRE's health expertise is available here.

Additional information about the USPSTF's preventive health expertise is available here.

If you would like further information, would like to give us feedback, or have any questions about this artifact, please contact us at ClinicalDecisionSupport@ahrq.hhs.gov.

IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.
Recommendation is copyrighted by USPSTF and administered by AHRQ
Implementation Details
Engineering Details
This CDS logic is expressed using Health Level Seven International (HL7) Clinical Quality Language (CQL) and the HL7 Fast Healthcare Interoperability Resources (FHIR) data model. All value sets referenced in the logic are published on the Value Set Authority Center (VSAC). Additional details about these resources can be accessed via the following URLs:
     CQL: https://ecqi.healthit.gov/cql
     FHIR DSTU2: https://www.hl7.org/fhir/DSTU2/index.html
     FHIR R4: https://hl7.org/fhir/R4/index.html
     VSAC: https://vsac.nlm.nih.gov/
Repository Information
Approval Date
Publication Date
Last Review Date
Knowledge Level

Structured code that is interpretable by a computer (includes data elements, value sets, logic)

Purpose and Usage

Identifies patients who are overweight or obese and, through the intervention text presented to patients, provides preventive health recommendations to:

  1. raise awareness of an identified risk (i.e., that the individual is overweight or obese and therefore at risk of developing prediabetes or type 2 diabetes)  
  2. provide information about the patient-specific risk(s) identified
  3. provide resources that will support the patient to act on the information (e.g., make lifestyle changes)
  4. encourage the patient to discuss the identified risk and preventive health recommendation with their clinician and explore the possibility of being screened for prediabetes
Intended Population
This artifact is intended for use in a broad population of adults (aged 35-70, or younger in certain populations) who are overweight or obese.

This CDS artifact is designed to be implemented in a patient-facing information technology (IT) system (e.g., a patient portal or health and wellness app) to deliver preventive health recommendations outside of a traditional encounter with a clinician. Organizations that might consider implementing this logic range from a large self-insured healthcare organization that seeks to provide health and wellness resources to their employees and patients, to a healthcare innovator that culls patient data from numerous sources (e.g., electronic health records, claims, pharmacy-based management systems, biometric devices, patient-reported data) to provide personalized wellness information via a mobile app.

It is intended for use by patients to provide patient-centered, evidence-based information on preventive treatment options to consider based on that patient’s individual health history and risk factors. The patient is provided with user-friendly notifications, educational materials, and tools in lay language to facilitate patient action and encourage collaborative decision-making between the patient and their clinician and caregiver(s) to determine the most appropriate treatment or care choice. 


This artifact represents the first half of the USPSTF recommendation: This artifact represents the first half of the USPSTF Prediabetes and Type 2 Diabetes: Screening recommendation (which identifies individuals who meet criteria to be screened for prediabetes and Type 2 DM). The second half of the recommendations (which encourages consideration of counseling if screening results are abnormal) is represented by a distinct artifact, Prediabetes and Type 2 Diabetes: Counseling. The CDS Connect team opted to develop two distinct artifacts from the one recommendation to simplify the logic and enable organizations to select portions of the recommendation that align with their organization's need.

Implementation consideration: The patient notifications included in the structured CQL expression of this artifact are general, enabling implementing organizations to expand upon and personalize the interventions based on their unique needs and patient population. Information provided to the patient translates the preventive care recommendation into lay language and provides additional resources in a user-friendly format and method. This user-friendly information facilitates patient action through the provision of vetted resources, and in the case of the customized piloted CDS, an opportunity to provide personalized motivational messaging and logistical support for appointments and followup. 

Additional information and resources: CQL Services, an open source, publicly available tool that facilitates integration of CQL code with a health IT system, was used during the pilot implementation of this artifact. CQL Services is available here

Supporting Evidence
Source Description

Derived from USPSTF guideline Prediabetes and Type 2 Diabetes: Screening


US Preventive Services Task Force. Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;326(8):736–743. doi:10.1001/jama.2021.12531

Jonas DE, Crotty K, Yun JDY, et al. Screening for Prediabetes and Type 2 Diabetes: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2021;326(8):744–760. doi:10.1001/jama.2021.10403


The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity. Clinicians should offer or refer patients with prediabetes to effective preventive interventions.

Strength of Recommendation

Grade B (see Appendix Table 1 for what the USPSTF Grades mean and suggestions for practice, available here)

Quality of Evidence
See full recommendation report for details regarding the Level of Certainty, available here.
Decision Notes
Artifact decision notes are outlined in Appendix A of the implementation guide attached to this artifact.
Artifact Representation
The pilot organization ran this logic every night as a batch report. Other implementers may opt for a different triggering event.

Patient is >=35 years old AND <=70 years old

        AND BMI >=25kg/m2, MOST RECENT VALUE

OR Patient is  >=18 years old and <35 years old

        AND BMI >=25kg/m2, MOST RECENT VALUE

        AND one of more of the following:

                Family history of diabetes

                OR polycystic ovary syndrome

                OR race = African American; American Indian or Alaskan Native; or Native Hawaiian or Pacific Islander

                OR ethnicity = Hispanic or Latino

OR Patient is >=18 years old and <=70 years old

        AND BMI >=23kg/m2, MOST RECENT VALUE

        AND race = Asian American

OR Patient is >=18 years old and <=70 years old

        AND gestational diabetes


Pregnancy (active)

OR pregnancy observation within the past 42 weeks (final, amended)

OR diabetes mellitus with the past 12 months (active, relapse)

OR prediabetes within the past 12 months (active, relapse)

OR impaired fasting glucose (IFG) within the past 12 months (active, relapse)

OR impaired glucose tolerance (IGT) within the past 12 months (active, relapse)

OR hemoglobin A1C test result, MOST RECENT VALUE within the past 3 years (final, amended)

OR fasting plasma glucose test result, MOST RECENT VALUE within the past 3 years (final, amended)

OR glucose tolerance test result, MOST RECENT VALUE within the past 3 years (final, amended)

Interventions and Actions

Display notification to patient: You may be at risk for (in other words, more likely to get) prediabetes and type 2 diabetes based on risk factors you may have. 

Many factors increase a person’s risk for high blood sugar including: being 35 years or older; being overweight; having a parent, brother or sister with diabetes; or if you are a woman with a history of  diabetes while pregnant (gestational diabetes) or polycystic ovarian syndrome (a condition where the ovaries produce higher-than-normal amounts of certain hormones). If you are African American, Hispanic, Alaskan Native, American Indian, Asian American, or Native Hawaiian/Pacific Islander you may also be more likely to have high blood sugar.

Recommendation: Experts (i.e., the US Preventive Services Task Force) recommend blood tests to measure blood sugar levels if you are at increased risk. If the tests show you have high blood sugar (prediabetes), there are steps you can take to help lower your blood sugar and prevent diabetes.

Contact your doctor to schedule an appointment and ask about being tested for high blood sugar and diabetes.

Here are some links to resources you may want to review:

  • Prediabetes: Your chance to prevent Type 2 diabetes (available here
  • Take steps to prevent type 2 diabetes (available here
  • The US Preventive Task Force Recommendation on “Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening” has been updated to "Prediabetes and Type 2 Diabetes: Screening" here.
Testing Experience
Pilot Experience

This artifact was tested by b.well® Connected Health over an 8-week period from June 2019 - August 2019, along with 4 other artifacts listed below (and published on the CDS Connect Repository).

  • Healthful Diet and Physical Activity for CVD Prevention in Adults with Cardiovascular Risk Factors
  • Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Part 2, Counseling
  • Statin Use for the Primary Prevention of CVD in Adults: Patient-Facing CDS Intervention
  • CMS's Million Hearts® Model Longitudinal ASCVD Risk Assessment Tool for Baseline 10-Year ASCVD Risk

b.well offers a platform with personalized health management resources targeted to consumers to help them self-manage the entire healthcare process. AHRQ and MITRE would like to thank b.well for their partnership on the pilot. The collaborative effort provided a valuable opportunity to test the CQL CDS expression and learn from the implementation process and end user experiences. High-level details are outlined below. Detailed information on the pilot implementation can be found in the CDS Connect Pilot Report: Preventive Health CDS Interventions document posted within this artifact. 

1. What went well?
·         The CDS was successfully integrated into the pilot site’s platform.            
·         The pilot partner was extremely collaborative and responsive, meeting all deadlines and exceeding expectations despite a very tight timeframe.
·         The use of several communication tools helped streamline the sharing of documentation and software, and enhanced the collaboration between the CDS Connect and b.well technical teams (i.e., Accellion kiteworks and Slack).
·         Leveraging the pilot partner’s expertise in patient/consumer engagement and health management resources and tools enhanced the pilot intervention process and contributed greatly to a successful pilot.
2. What did not go well?
·         The pilot technical team did not have prior experience with the standards used (e.g., Fast Healthcare Interoperability Resources [FHIR], CDS Hooks, and Clinical Quality Language [CQL]), which extended the technical integration time and efforts.
·         Data mapping consumed almost 25 percent of the pilot partner’s technical resource hours (80 hours) and an additional 20 hours of clinical and data/analytics resource time.
·         Some required data was simply not available. Given more time, the pilot partner could have enhanced existing capabilities to obtain the required data directly from the end users.
3. What would you do differently?
·         Initiate the pilot partnership no later than March to allow more time for integration and testing efforts, as well as end user engagement.
·         If more time was available, consider implementing  the CDS using the FHIR Release 4 (R4) in addition to FHIR Draft Standard for Trial Use 2 (DSTU2).
4. What enhancements were suggested by the pilot partner?
·         Allow the calculation of an “inferred” diagnosis or potential “at risk” status for end users without a confirmed diagnosis, based on other available data. This would enable reaching a larger population of end users and providing them with education that may be valuable. The CDS Connect team opted not to implement this enhancement since expansion of the target population would diverge from the USPSTF recommendation.
·         If time had allowed, it would have been helpful to obtain end user input on the educational materials prior to implementing them. Instead, the pilot partner used health literacy and health communication best practices when developing the educational content.
·         It would have been helpful to survey a larger number of end users, and to provide the survey to the user directly after the intervention. This would allow more conclusive analysis of the survey results; however, the project team was required to follow Paperwork Reduction Act requirements which limited the number of survey recipients to 9 or less
·         Provision of more detailed information from CDS Hooks, to provide information such as the specific user data that qualified that user for the CDS intervention. This information could be used for both testing purposes as well as personalization of the intervention text.
5. What were the key takeaways/lessons learned from the pilot experience?
·         Aggregating data from multiple sources provides a rich source of clinical information, but also presents challenges when using the data to satisfy CDS logic requirements. This is primarily due to the lack of standards employed by each data source (e.g., claims, electronic health systems, pharmacy benefits management systems, reference laboratories, and patient-generated health data). Much of the data were not linked to a standard clinical terminology code, and many of the required FHIR attributes were missing (e.g., “status,” “verificationStatus,” “onsetDateTime,” “valueQuantity”).
·         Data mapping to account for the issues listed above is a resource-intensive process that also requires knowledgeable clinical informatics expertise. The mapping efforts can impact the integration timeline.
·         The experience of the pilot technical team with FHIR and other evolving standards should be considered during the technical evaluation and planning stages.
·         Patient-facing CDS pilots should consider a pilot partner with consumer/patient-facing experience and expertise and should ensure a pilot timeframe that allows end user personalization and engagement opportunities to be realized.