Frequently Asked Questions

Who can use CDS Connect?

Anybody! CDS Connect is freely available for anyone to use. Generally, the following populations will find CDS Connect valuable:

Clinicians
Clinical Informaticists
CQL developers
Health IT Vendors
Anyone with an interest in shaping how clinical decision support is developed

All website visitors can browse and download content. Additionally, you can register with CDS Connect to create, edit, publish, and subscribe to clinical decision support artifacts.

What is a CDS artifact?

CDS artifacts are items that represent medical knowledge from various knowledge sources (e.g. clinical guidelines, peer-reviewed articles, local best practices, and Clinical Quality Measures). The artifacts can take many forms, but the goal is to create computable, interoperable translations using CQL. For more information, see knowledge levels discussion (Boxwala et al. JAMIA vol. 18 Suppl 1, 2011).

What is CQL?

CQL is a data standard governed by Health Level Seven (HL7) that is currently a Standard for Trial Use (STU). CQL expresses logic in a human-readable document that is also structured enough for electronic processing of a query. It can be used within both the Clinical Decision Support (CDS) and Clinical Quality Measurement (CQM) domains .

For more information, see the eCQI Resource Center.

Why does CDS Connect exist?

CDS Connect is a project funded by the Agency for Healthcare Research and Quality to advance evidence into clinical practice through CDS and to make CDS more shareable, standards-based, and publicly-available.

For more information, visit the About page.

How do I find artifacts that are relevant to my organization?

As of August 2021, the Repository held 64 CDS artifacts. The CDS artifacts in the Repository span several clinical domains including, but not limited to, cardiovascular disease, preventive care, chronic pain management, alcohol use, hyper- and hypo-glycemia, mental health, and drug-drug interactions. Artifacts are contributed by a variety of organizations, including Federal agencies and academic institutions. Several have been piloted in practices and modified/enhanced based on user experience.

You can search for CDS artifacts various ways such as: by type, description, keyword, title, topic, and publisher, as well as filter the CDS artifacts by topic area.

For more information, visit the Repository.

How can I contribute CDS artifacts to the Repository?

The process entails coordinating with the CDS Connect project team on expected data and formats, setting up author credentials, submitting the material for review, working through any feedback, and then publishing the content.

Once you have author credentials, you can find documentation on how to use the accounts in the July 2018 work group slides: https://cds.ahrq.gov/sites/default/files/workgroups/671/july-2018-cds-connect-wg-ppt.pdf

We look forward to hearing from you! To begin the process, please contact us.

How do I register for a CDS Connect Account?

To register, select your permissions, and submit the CDS signup form:

Authoring Permissions are for software developers to create HL7 CQL-based CDS logic files using a friendly web interface and to test authored CDS logic against uploaded synthetic patient data.
Contributor Permissions are for researchers and developers to create CDS artifacts at the multiple knowledge levels (L1-L4) and post them to the Repository for public review and use.
Community Member Permissions are for anyone with an interest in clinical decision support to subscribe to Repository artifacts and receive notifications.

The system administrator will review and approve your request within one business day. Once approved, you will receive a confirmation email with a link to reset your password.

With your new password, you can log in to the CDS Authoring Tool to create clinical decision support logic.

Or you might use the same credentials to log in separately to your CDS Connect Repository Account to post and subscribe to CDS artifacts.

If I upload artifacts to CDS Connect, does the copyright status of those artifacts change?

Copyright and stewardship of CDS artifacts original to CDS Connect (i.e., developed in coordination with AHRQ and the Health FFRDC, operated by the MITRE Corporation) is being managed on a case-by-case basis with AHRQ.

Third party contributors of CDS artifacts to the Repository are required to provide an attestation of their authority to distribute the artifact, which does not change the copyright status of the work. Depending on the use of the contribution, CDS Connect may request additional permissions from the contributor.

For more information about copyright considerations, please contact us.

How can I assert my copyright?

In the event that you are the owner of the copyright in any of the material on this website and do not consent to the use of your material in accordance with the terms and conditions of use of this website, please contact us providing the information requested in the form and we will withdraw your material from our website within five working days of receipt of your written objection and proof of ownership of the aforementioned material.

In order to process your request, please provide all information required in the form. Note that to be effective under applicable law, your notification of claimed infringement must be a written communication provided to the designated agent of CDS Connect that includes substantially all the information requested in the form.

When completed and submitted your form will be sent to the to the CDS Connect Designated Agent, also reachable at the following address: ClinicalDecisionSupport@ahrq.hhs.gov

It is strongly recommended that you submit your information using the form, which will be delivered to the email address above.

Your request will be acknowledged within five working days of receipt.

How do I maintain my contributed CDS artifacts?

First, you will need to determine if your artifact is expected to undergo content review and update; not all artifacts do. You can determine the content review and update expectation based on the Experimental and Status metadata associated with your CDS artifact, and using the metadata responses to review the table below. Please contact us if you are unsure which responses apply to your artifact.

Regardless of what you determine about your artifact by reviewing the table, any associated documentation (i.e., human-readable, downloadable files) posted with your artifact must meet Section 508 accessibility requirements. In other words, at the minimum, your artifact documents will need to be accessible to be considered properly maintained.

Artifact Metadata Field	Response Selected	Content Review & Update Expectation
Experimental¹	Yes	No expectation for review and update.
	No	Expectation for review and update determined by response to ‘Status’ metadata field.
Status²	Draft	No expectation for review and update.
	Active	Annual review and update is expected. Follow the five steps outlined below. Note: Artifacts will denote a temporary ‘Draft’ status while your update is in process if the answer to either of the following questions is ‘Yes’: Does new evidence exist which, if not incorporated, might result in harm to a patient? Is there a new/updated standard of care which is viewed as “best practice” by professional organizations (e.g. American College of Cardiology)?
	Retired	No expectation for review and update. Note: 'Retired' artifacts have the option to invite members of the CDS Community to continue development of the CDS artifact.
	Unknown	Review and update process may be expected, based on if intent is to move artifact to 'Active' Status.

¹Experimental – Is ‘Yes’ if this artifact is authored for testing purposes (or education/evaluation/marketing) and is not intended to be used for genuine usage in a clinical setting.

²Status – Can be ‘Draft’ (under development, not ready for normal use), ‘Active’ (ready for normal use), ‘Retired’ (withdrawn or superseded, no longer of use), or ‘Unknown’ (status unclear).

Again, please contact us if you are unsure which responses apply to your artifact. We'd be happy to help you decide.

Based on the applicable expectations captured in this table, review your artifact according to the following steps.

Step 1: Is the evidence behind the CDS artifact still current?

Determine whether the primary source of evidence (e.g., United States Preventative Services Task Force (USPSTF) recommendation; Centers for Disease Control and Prevention (CDC) guidance; Veterans Administration/Department of Defense (VA/DoD) clinical practice guideline; AHRQ comparative evidence review; risk assessment tools; recommendation of an expert panel) has been updated since the artifact was developed.
- If the primary source has been updated, then perform a detailed analysis of the new evidence.
  - Determine where it aligns and where it diverges from the existing evidence and decide whether an update is warranted.
  - If the evidence is not a guideline published by an organizational authority, then engage a librarian, subject matter experts (SMEs), and/or the guideline author as needed.
  - Identify all aspects of the artifact that need to be updated in consultation/collaboration with the informaticist, logic author, and/or Clinical Quality Language (CQL) developer.
  - Consult the decision log during this analysis, as sometimes decisions that appear contrary to evidence have an educated rationale.
- If the primary source has not been updated, then determine whether the evidence refreshes “off cycle.” If it does, then include the appropriate timeline into the artifact’s metadata so viewers understand that the artifact may need to be updated before the next annual review.
- If the primary source refreshes more frequently than annually, then develop an internal check system to ascertain when updated.

Step 2: Are the value sets (VSs) still current?

Confirm that each VS has been updated in the Value Set Authority Center (VSAC), and that the update reflects any code system updates as well.
Identify any additions or deletions to the VS in the CDS artifact.
Determine if any VS or codes published since the last update present a better fit for the CDS artifact.
- If so, consult with the clinician to compare options for best clinical “fit.”
- If the new material is an improved “fit,” then ensure that its object identifier (OID) replaces the existing OID and is updated in the CQL, which may impact the metadata, the decision log, data requirement form, documentation, and other supporting materials.
  - Be sure to consult the decision log during this analysis; decisions sometimes appear contrary to evidence, yet the decision log captures the rationale for the dilemma.
  - Coordinate with CQL SMEs to perform the update and to publish a new version of CQL code.
Determine if any Publishing Organization-created VSs were used in the artifact.
- If they are, then the VS will need to be updated. Review the terminologies within each VS to see if any new codes should be included in the VS.
- If possible, convert those to intensional OIDs.

Step 3: Do the evidence or VS changes require an update to the logic?

If so, add or replace VS and code references based on assessments with clinician/informaticist.
In addition, determine the required types of changes in logic; update any structured logic files accordingly.

Step 4: Do the relevant Implementation Guide (IG) and/or other supporting documents need updates?

Based on the prior steps, determine what documentation updates are required.
- Edit each relevant section of the IG (e.g., include a description of new evidence, VS, or logic; knowledge level; receipt of implementation feedback from a pilot, explanation of impact of technical changes to users, updates to clinician- or patient-facing text).
- Add new decisions about evidence, VS, CQL, etc. to the Decision Log.
- Update the Change Log to clearly describe what was changed in the new version.
- Have the IG (and any other documents) reviewed and edited so that the new document(s) conform to Section 508 accessibility requirements.

Step 5: Are the metadata still current?

Using the Repository editing interface, identify fields in the Repository CDS Artifact entry page that may need updates.
Review and update existing metadata for usability aspects (e.g., spelling errors; broken hyperlinks; information about retaining multiple versions of the logic, if relevant).
Update metadata fields impacted by changes in the underlying evidence and logic representations.
Perform virus scans as appropriate.

Here is a one-page summary of the entire process for your reference.

This review process is dynamic and influenced by best practices, lessons learned, and feedback from the CDS Community! Please contact us to share your feedback.