CMS and others are encouraging medical groups to reduce CV risk in diabetes patients and other high risk adults. Electronic health record (EHR)-linked point of care Clinical Decision Support systems (CDS) can support this effort, and basic EHR-linked CDS that provides patient-specific treatment recommendations has previously been shown to significantly improve glucose and some aspects of BP control in diabetes patients. To compare the performance of this basic CDS versus an enhanced CDS system (with prioritized CDS to both patient and provider), we group randomized 6561 adults with diabetes to receive basic versus enhanced CDS. Over a median of 14 months of follow-up, Framingham 10-year absolute risk of fatal or nonfatal heart attack or stroke declined from 27.8% to 24.8%, and Framingham reversible CV risk (net of age and sex) declined from 12.6% to 9.6%. The proportion of subjects achieving goals increased for BP (40.7% to 78.3%), LDL (55.8% to 71.1%), and A1c (68.4% to 72.4%), and smoking declined from 29.4% to 23.4%. We conclude that enhanced CDS was not superior to basic CDS, but that both CDS systems were associated with sustained clinically and statistically (p<.05) significant reduction in CV risk in diabetes patients.