feat: don't simply toss extensions

- Print a report at the end of the ETL run of all extensions stripped by resource, URL, and count. - Plus a report on resources skipped due to unrecognized modifier extensions. - Leave stub extension in place, with just the `url` field, so that we can inspect stripped extensions in SQL if we want. Allow the following new extensions: - http://hl7.org/fhir/StructureDefinition/data-absent-reason - http://hl7.org/fhir/StructureDefinition/derivation-reference - http://hl7.org/fhir/StructureDefinition/event-performerFunction - http://hl7.org/fhir/StructureDefinition/iso21090-PQ-translation - http://hl7.org/fhir/StructureDefinition/rendered-value - http://hl7.org/fhir/us/core/StructureDefinition/us-core-jurisdiction - http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication- adherence - http://hl7.org/fhir/us/core/StructureDefinition/us-core-sex - http://hl7.org/fhir/us/core/StructureDefinition/us-core-tribal- affiliation - https://fhir-ehr.cerner.com/r4/StructureDefinition/client- organization - https://fhir-ehr.cerner.com/r4/StructureDefinition/pharmacy- verification-status - https://fhir-ehr.cerner.com/r4/StructureDefinition/precision - http://electronichealth.se/fhir/StructureDefinition/NLLDosePackaging - http://electronichealth.se/fhir/StructureDefinition/ NLLPrescriptionFormat - http://electronichealth.se/fhir/StructureDefinition/ NLLRegistrationBasis Ignore the following extensions: - http://hl7.org/fhir/StructureDefinition/iso21090-TEL-address - http://hl7.org/fhir/us/core/StructureDefinition/us-core-direct - https://fhir-ehr.cerner.com/r4/StructureDefinition/clinical- instruction - https://fhir-ehr.cerner.com/r4/StructureDefinition/estimated- financial-responsibility-amount Drop support for the following extension: - http://hl7.org/fhir/us/core/StructureDefinition/us-core-sex-for- clinical-use (this was in US Core 6.0 ballot, but didn't make final cut - it seems to be replaced by just 'us-core-sex')
smart-on-fhir · Nov 1, 2024 · 1af1fc4 · 1af1fc4
1 parent 1ae37fd
commit 1af1fc4
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diff --git a/cumulus_etl/deid/ms-config.json b/cumulus_etl/deid/ms-config.json
@@ -20,17 +20,10 @@
   "fhirVersion": "R4",
   "processingErrors": "raise",
   "fhirPathRules": [
-    // Only allow a few known extensions
-    {"path": "Patient.extension('http://hl7.org/fhir/Profile/us-core#ethnicity')", "method": "keep"}, // Old DSTU1 URL, still out there in the wild: https://www.hl7.org/fhir/DSTU1/us-core.html
-    {"path": "Patient.extension('http://hl7.org/fhir/Profile/us-core#race')", "method": "keep"}, // Old DSTU1 URL, still out there in the wild: https://www.hl7.org/fhir/DSTU1/us-core.html
-    {"path": "Patient.extension('http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex')", "method": "keep"},
-    {"path": "Patient.extension('http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity')", "method": "keep"},
-    {"path": "Patient.extension('http://hl7.org/fhir/us/core/StructureDefinition/us-core-genderIdentity')", "method": "keep"},
-    {"path": "Patient.extension('http://hl7.org/fhir/us/core/StructureDefinition/us-core-race')", "method": "keep"},
-    {"path": "Patient.extension('http://hl7.org/fhir/us/core/StructureDefinition/us-core-sex-for-clinical-use')", "method": "keep"},
-    {"path": "Patient.extension('http://open.epic.com/FHIR/StructureDefinition/extension/sex-for-clinical-use')", "method": "keep"}, // Epic has used this pre-final-spec URL
-    {"path": "nodesByName('modifierExtension')", "method": "keep"}, // keep these so we can ignore resources with modifiers we don't understand
-    {"path": "nodesByType('Extension')", "method": "redact"}, // drop all unknown extensions
+    // modifierExtension is handled by ETL so that we can skip resources we don't understand
+    {"path": "nodesByName('modifierExtension')", "method": "keep"},
+    // extension is handled by ETL so that we can flag the URLs of extensions we strip
+    {"path": "nodesByName('extension')", "method": "keep"},
 
     // Elements that might be embedded and kept elsewhere -- redact pieces of the whole
     {"path": "nodesByType('Attachment').title", "method": "redact"},
@@ -56,6 +49,7 @@
     {"path": "nodesByType('Dosage').sequence", "method": "keep"},
     // Skip Dosage.text
     {"path": "nodesByType('Dosage').additionalInstruction", "method": "keep"},
+    // Skip Dosage.patientInstruction
     {"path": "nodesByType('Dosage').timing", "method": "keep"},
     {"path": "nodesByType('Dosage').asNeeded", "method": "keep"},
     {"path": "nodesByType('Dosage').site", "method": "keep"},

diff --git a/cumulus_etl/deid/scrubber.py b/cumulus_etl/deid/scrubber.py
@@ -4,10 +4,18 @@
 import tempfile
 from typing import Any
 
-from cumulus_etl import fhir
+import rich
+import rich.padding
+import rich.tree
+
+from cumulus_etl import common, fhir
 from cumulus_etl.deid import codebook, mstool, philter
 
 
+# Record of unknown extensions (resource type -> extension URL -> count)
+ExtensionCount = dict[str, dict[str, int]]
+
+
 class SkipResource(Exception):
     pass
 
@@ -34,6 +42,10 @@ def __init__(self, codebook_dir: str | None = None, use_philter: bool = False):
         self.codebook = codebook.Codebook(codebook_dir)
         self.codebook_dir = codebook_dir
         self.philter = philter.Philter() if use_philter else None
+        # List of ignored extensions (resource -> url -> count)
+        self.dropped_extensions: ExtensionCount = {}
+        # List of modifier extensions that caused us to skip a resource (resource -> url -> count)
+        self.skipped_modifer_extensions: ExtensionCount = {}
 
     @staticmethod
     async def scrub_bulk_data(input_dir: str) -> tempfile.TemporaryDirectory:
@@ -48,7 +60,9 @@ async def scrub_bulk_data(input_dir: str) -> tempfile.TemporaryDirectory:
         await mstool.run_mstool(input_dir, tmpdir.name)
         return tmpdir
 
-    def scrub_resource(self, node: dict, scrub_attachments: bool = True) -> bool:
+    def scrub_resource(
+        self, node: dict, scrub_attachments: bool = True, keep_stats: bool = True
+    ) -> bool:
         """
         Cleans/de-identifies resource (in-place) and returns False if it should be rejected
 
@@ -57,14 +71,19 @@ def scrub_resource(self, node: dict, scrub_attachments: bool = True) -> bool:
 
         :param node: resource to de-identify
         :param scrub_attachments: whether to remove any attachment data found
+        :param keep_stats: whether to records stats about this resource
         :returns: whether this resource is allowed to be used
         """
         try:
             self._scrub_node(
-                node.get("resourceType"), "root", node, scrub_attachments=scrub_attachments
+                node.get("resourceType"),
+                "root",
+                node,
+                scrub_attachments=scrub_attachments,
+                keep_stats=keep_stats,
             )
-        except SkipResource as exc:
-            logging.warning("Ignoring resource of type %s: %s", node.__class__.__name__, exc)
+        except SkipResource:
+            # No need to log, we'll have already reported out what we should
             return False
         except ValueError as exc:
             logging.warning("Could not parse value: %s", exc)
@@ -86,14 +105,30 @@ def save(self) -> None:
         if self.codebook_dir:
             self.codebook.db.save(self.codebook_dir)
 
+    def print_extension_report(self) -> None:
+        self._print_extension_table(
+            "Unrecognized extensions dropped from resources:",
+            self.dropped_extensions,
+        )
+        self._print_extension_table(
+            "🚨 Resources skipped due to unrecognized modifier extensions: 🚨",
+            self.skipped_modifer_extensions,
+        )
+
     ###############################################################################
     #
     # Implementation details
     #
     ###############################################################################
 
     def _scrub_node(
-        self, resource_type: str, node_path: str, node: dict, scrub_attachments: bool
+        self,
+        resource_type: str,
+        node_path: str,
+        node: dict,
+        *,
+        scrub_attachments: bool,
+        keep_stats: bool,
     ) -> None:
         """Examines all properties of a node"""
         for key, values in list(node.items()):
@@ -106,7 +141,13 @@ def _scrub_node(
 
             for value in values:
                 self._scrub_single_value(
-                    resource_type, node_path, node, key, value, scrub_attachments=scrub_attachments
+                    resource_type,
+                    node_path,
+                    node,
+                    key,
+                    value,
+                    scrub_attachments=scrub_attachments,
+                    keep_stats=keep_stats,
                 )
 
     def _scrub_single_value(
@@ -116,12 +157,17 @@ def _scrub_single_value(
         node: dict,
         key: str,
         value: Any,
+        *,
         scrub_attachments: bool,
+        keep_stats: bool,
     ) -> None:
         """Examines one single property of a node"""
         # For now, just manually run each operation. If this grows further, we can abstract it more.
         self._check_ids(node, key, value)
-        self._check_modifier_extensions(key, value)
+        if self._check_extensions(resource_type, node, key, value, keep_stats=keep_stats):
+            keep_stats = False  # disable stats underneath an extension
+        if self._check_modifier_extensions(resource_type, key, value, keep_stats=keep_stats):
+            keep_stats = False  # disable stats underneath a modifierExtension
         self._check_security(node_path, node, key, value)
         self._check_text(node, key, value)
         if scrub_attachments:
@@ -130,26 +176,121 @@ def _scrub_single_value(
         # Recurse if we are holding another FHIR object (i.e. a dict instead of a string)
         if isinstance(value, dict):
             self._scrub_node(
-                resource_type, f"{node_path}.{key}", value, scrub_attachments=scrub_attachments
+                resource_type,
+                f"{node_path}.{key}",
+                value,
+                scrub_attachments=scrub_attachments,
+                keep_stats=keep_stats,
             )
 
+    def _print_extension_table(self, title: str, table: ExtensionCount) -> None:
+        if not table:
+            return  # nothing to do!
+
+        common.print_header(title)
+        for resource_type in sorted(table):
+            tree = rich.tree.Tree(resource_type)
+            for url, count in sorted(table[resource_type].items()):
+                tree.add(f"{url} ({count:,} time{'' if count == 1 else 's'})")
+            indented = rich.padding.Padding.indent(tree, 1)
+            rich.get_console().print(indented)
+
     ###############################################################################
     #
     # Individual checkers
     #
     ###############################################################################
 
-    @staticmethod
-    def _check_modifier_extensions(key: str, value: Any) -> None:
+    def _count_unknown_extension(self, table: ExtensionCount, resource: str, url: str) -> None:
+        resource_counts = table.setdefault(resource, {})
+        count = resource_counts.setdefault(url, 0)
+        resource_counts[url] = count + 1
+
+    def _check_extensions(
+        self, resource_type: str, node: dict, key: str, value: Any, *, keep_stats: bool
+    ) -> None:
+        """If there's any unrecognized extensions, log and delete them"""
+        if key == "extension" and isinstance(value, dict):
+            # We want to allow almost any extension that might have clinical relevance.
+            # But we use an allow list to avoid letting in PHI.
+            allowed_extensions = {
+                ### Base spec extensions
+                ### (See https://www.hl7.org/fhir/R4/extensibility-registry.html)
+                "http://hl7.org/fhir/StructureDefinition/data-absent-reason",
+                "http://hl7.org/fhir/StructureDefinition/derivation-reference",
+                "http://hl7.org/fhir/StructureDefinition/event-performerFunction",
+                "http://hl7.org/fhir/StructureDefinition/iso21090-PQ-translation",
+                "http://hl7.org/fhir/StructureDefinition/rendered-value",
+                ### US Core extensions
+                ### (See https://hl7.org/fhir/us/core/profiles-and-extensions.html)
+                "http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex",
+                "http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity",
+                "http://hl7.org/fhir/us/core/StructureDefinition/us-core-genderIdentity",
+                "http://hl7.org/fhir/us/core/StructureDefinition/us-core-jurisdiction",
+                "http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication-adherence",
+                "http://hl7.org/fhir/us/core/StructureDefinition/us-core-race",
+                "http://hl7.org/fhir/us/core/StructureDefinition/us-core-sex",
+                "http://hl7.org/fhir/us/core/StructureDefinition/us-core-tribal-affiliation",
+                ### Next two are old US Core DSTU1 URLs, still seen in the wild
+                ### (See https://www.hl7.org/fhir/DSTU1/us-core.html)
+                "http://hl7.org/fhir/Profile/us-core#ethnicity",
+                "http://hl7.org/fhir/Profile/us-core#race",
+                ### Cerner extensions
+                # Links to a client Organization reference in an Encounter
+                "https://fhir-ehr.cerner.com/r4/StructureDefinition/client-organization",
+                # "precision" here is the precision of a date field
+                "https://fhir-ehr.cerner.com/r4/StructureDefinition/precision",
+                # Some medication extensions used by Cerner
+                "https://fhir-ehr.cerner.com/r4/StructureDefinition/pharmacy-verification-status",
+                "http://electronichealth.se/fhir/StructureDefinition/NLLDosePackaging",
+                "http://electronichealth.se/fhir/StructureDefinition/NLLPrescriptionFormat",
+                "http://electronichealth.se/fhir/StructureDefinition/NLLRegistrationBasis",
+                ### Epic extensions
+                "http://open.epic.com/FHIR/StructureDefinition/extension/sex-for-clinical-use",
+            }
+            # Some extensions we know about, but aren't necessary to us (they duplicate standard
+            # extensions, contain PHI, or are otherwise not relevant). We don't want to warn
+            # the user about them as "unrecognized", so we just ignore them entirely.
+            ignored_extensions = {
+                # Base spec extension holding a phone number
+                "http://hl7.org/fhir/StructureDefinition/iso21090-TEL-address",
+                # US Core extension, but deals with how to email a person, which we don't need
+                "http://hl7.org/fhir/us/core/StructureDefinition/us-core-direct",
+                # Cerner dosage instruction freeform text extension, could have PHI
+                "https://fhir-ehr.cerner.com/r4/StructureDefinition/clinical-instruction",
+                # Cerner financial extension for Encounters, we don't need to record this
+                "https://fhir-ehr.cerner.com/r4/StructureDefinition/estimated-financial-responsibility-amount",
+            }
+            url = value.get("url")
+            if url not in allowed_extensions:
+                value.clear()  # get rid of any other keys
+                value["url"] = url  # just keep the url, to track that it existed
+                if keep_stats and url not in ignored_extensions:
+                    self._count_unknown_extension(self.dropped_extensions, resource_type, url)
+            return True
+        return False
+
+    def _check_modifier_extensions(
+        self, resource_type: str, key: str, value: Any, *, keep_stats: bool
+    ) -> None:
         """If there's any unrecognized modifierExtensions, raise a SkipResource exception"""
         if key == "modifierExtension" and isinstance(value, dict):
-            known_extensions = [
+            allowed_extensions = {
+                # These NLP extensions are generated by ctakesclient's text2fhir code.
+                # While we don't anticipate ingesting any resources using these extensions
+                # (and we don't currently generate them ourselves), we might in the future.
                 "http://fhir-registry.smarthealthit.org/StructureDefinition/nlp-polarity",
                 "http://fhir-registry.smarthealthit.org/StructureDefinition/nlp-source",
-            ]
+            }
             url = value.get("url")
-            if url not in known_extensions:
-                raise SkipResource(f'Unrecognized modifierExtension with URL "{url}"')
+            if url not in allowed_extensions:
+                if keep_stats:
+                    self._count_unknown_extension(
+                        self.skipped_modifer_extensions, resource_type, url
+                    )
+                raise SkipResource
+            return True
+        return False
 
     def _check_ids(self, node: dict, key: str, value: Any) -> None:
         """Converts any IDs and references to a de-identified version"""

diff --git a/cumulus_etl/etl/cli.py b/cumulus_etl/etl/cli.py
@@ -27,17 +27,16 @@
 
 
 async def etl_job(
-    config: JobConfig, selected_tasks: TaskList, use_philter: bool = False
+    config: JobConfig, selected_tasks: TaskList, scrubber: deid.Scrubber
 ) -> list[JobSummary]:
     """
     :param config: job config
     :param selected_tasks: the tasks to run
-    :param use_philter: whether to run text through philter
+    :param scrubber: de-id scrubber to use for jobs
     :return: a list of job summaries
     """
     summary_list = []
 
-    scrubber = deid.Scrubber(config.dir_phi, use_philter=use_philter)
     for task_class in selected_tasks:
         task = task_class(config, scrubber)
         task_summaries = await task.run()
@@ -374,14 +373,18 @@ async def etl_main(args: argparse.Namespace) -> None:
         common.write_json(config.path_config(), config.as_json(), indent=4)
 
         # Finally, actually run the meat of the pipeline! (Filtered down to requested tasks)
-        summaries = await etl_job(config, selected_tasks, use_philter=args.philter)
+        scrubber = deid.Scrubber(config.dir_phi, use_philter=args.philter)
+        summaries = await etl_job(config, selected_tasks, scrubber)
 
     # Update job context for future runs
     job_context.last_successful_datetime = job_datetime
     job_context.last_successful_input_dir = args.dir_input
     job_context.last_successful_output_dir = args.dir_output
     job_context.save()
 
+    # Report out any stripped extensions or dropped resources due to modiferExtensions
+    scrubber.print_extension_report()
+
     # Flag final status to user
     common.print_header()
     if any(s.had_errors for s in summaries):

diff --git a/cumulus_etl/etl/tasks/nlp_task.py b/cumulus_etl/etl/tasks/nlp_task.py
@@ -78,7 +78,7 @@ async def read_notes(
             can_process = (
                 nlp.is_docref_valid(docref)
                 and (doc_check is None or doc_check(docref))
-                and self.scrubber.scrub_resource(docref, scrub_attachments=False)
+                and self.scrubber.scrub_resource(docref, scrub_attachments=False, keep_stats=False)
             )
             if not can_process:
                 continue

diff --git a/docs/deid.md b/docs/deid.md
@@ -97,18 +97,25 @@ Zip codes are redacted down to just the first three digits (e.g. `12139` becomes
 Additionally, for certain small-population zip codes where even three digits is too identifying,
 the zip code is entirely redacted to `00000`.
 
-#### Extensions
-
-All extensions are removed, except for:
-- The USCDI patient extensions (birth sex, gender identity, race, and ethnicity)
-- "Modifier" extensions which will flag to the ETL that a resource should be skipped
-
 #### Clinical Notes
 
 Be aware that clinical notes are not removed at this stage.
 They are kept for now, so that Cumulus ETL can run natural language processing on them.
 See below for more information on that.
 
+### Extensions
+
+Extensions are stripped out unless they are on a list of recognized extensions,
+to ensure that PHI doesn't accidentally slip in.
+The allowed extensions include the standard USCDI patient extensions
+(birth sex, gender identity, race, and ethnicity)
+as well as various harmless vendor extensions.
+
+Any unrecognized
+["Modifier" extension](https://www.hl7.org/fhir/R4/extensibility.html#modifierExtension)
+will cause Cumulus ETL to entirely skip the containing resource,
+since the resource can't be properly understood.
+
 ### IDs
 
 Cumulus ETL de-identifies FHIR resource IDs itself.