For hospital inpatient quality eCQM program for CY2021 reporting period , I have 3 cases where the Stroke-2 outcome within the CMS HQR portal  is different than expected.  In all 3 cases, the CMS HQR outcome is showing as meeting denominator only, and not meeting the numerator.  However, within our EHR and within our internal QRDA files I am showing an antithrombotic medication at discharge for the patients, and there is an RX Norm code attached which is on the CMS value set.  When I look at the QRDA file, I can see the antithrombotic medication listed along with the Rx norm code, and the date and time is the same as the discharge date and time,  so I  can not tell why these cases would not meet the numerator.

These examples are as follows:

CCN: 520102 (Aurora Lakeland Medical Center), Q2 2021, Batch ID: 3563195, file name: 520102_Z22100251_996119.xml

CCN: 520138 (Aurora St. Luke's Medical Center), Q2 2021, Batch ID: 3570607, file name: 520138_Z23052376_2035220.xml

CCN: 520138 (Aurora St. Luke's Medical Center), Q3 2021, Batch ID: 3588808, file name: 520138_Z22553537_1523700.xml