journal article·2023-09-06Open access

Cybersecurity and Medical Imaging: A Simulation-Based Approach to DICOM Communication

Stylianos Karagiannis, Emmanouil Magkos, Christoforos Ntantogian, Ricardo Cabecinha, Theofanis Fotis

Applied Sciences· Volume 13· Issue 18

Abstract

Medical imaging plays a crucial role in modern healthcare, providing essential information for accurate diagnosis and treatment planning. The Digital Imaging and Communications in Medicine (DICOM) standard has revolutionized the storage, transmission, and sharing of medical images and related data. Despite its advantages, implementation and deployment of the DICOM protocol often suffers from incomplete understanding, leading to vulnerabilities within the healthcare ecosystem. This research paper presents an implementation of DICOM communication and the development of a practical demonstration for simulation purposes The simulation can be used for conducting cybersecurity tests in the context of DICOM communication. Overall, the simulation provides a digital environment that can help in retrieving valuable insights into the practical aspects of DICOM communication and PACS integration, serving as a valuable resource for medical imaging professionals, researchers, and developers. These research results provide practical insights, and the DICOM simulation can be used in realistic contexts to showcase a variety of security scenarios.
Source: crossref · Quality: baseline

Research context

OpenAlex topics: Digital Radiography and Breast Imaging · Artificial Intelligence in Healthcare and Education · Big Data Technologies and Applications

SciVX discovery tags are terminology-based. OpenAlex topics are source-provided classifications.

Affiliations

PDMFC, R. Fradesso da Silveira, 4-1B, 1300-609 Lisboa, Portugal

Department of Informatics, Ionian University, Plateia Tsirigoti 7, 49100 Corfu, Greece

Hospital do Espírito Santo de Évora, EPE, Largo Senhor da Pobreza, 7000-811 Évora, Portugal

Centre for Secure, Intelligent and Usable Systems (CSIUS), School of Sport & Health Sciences, University of Brighton, Brighton BN2 4AT, UK

Funding

European Union’s Horizon 2020 Research and Innovation Programme

References (52)

Show source-provided references
1. Medical imaging: From roentgen to the digital revolution, and beyond10.5041/RMMJ.10355 ↗
2. Big data in healthcare: Management, analysis and future prospects10.1186/s40537-019-0217-0 ↗
3. Picture archiving and communication system (PACS): Medical perspectives
4. Machine learning: Applications of artificial intelligence to imaging and diagnosis10.1007/s12551-018-0449-9 ↗
5. Reliability and validity analysis of MediaPipe-based measurement system for some human rehabilitation motions10.1016/j.measurement.2023.112826 ↗
6. A New Home-Based Upper-and Lower-Limb Telerehabilitation Platform with Experimental Validation10.1007/s13369-023-07720-0 ↗
7. Molecular imaging for cancer diagnosis and surgery10.1016/j.addr.2013.09.007 ↗
8. Understanding and using DICOM, the data interchange standard for biomedical imaging10.1136/jamia.1997.0040199 ↗
9. Lebre, R., and Costa, C. (2021, January 18–19). An Efficient and Reliable Architecture for Distributing Medical Imaging Data. Proceedings of the 2021 International Conference on e-Health and Bioengineering (EHB), Iasi, Romania.10.1109/EHB52898.2021.9657638 ↗
10. Supriya, S., and Padaki, S. (2016, January 15–18). Data security and privacy challenges in adopting solutions for IOT. Proceedings of the 2016 IEEE International Conference on Internet of Things (iThings) and IEEE Green Computing and Communications (GreenCom) and IEEE Cyber, Physical and Social Computing (CPSCom) and IEEE Smart Data (SmartData), Chengdu, China.10.1109/iThings-GreenCom-CPSCom-SmartData.2016.97 ↗
11. Jeyakumar, V., Abirami, K.R., Saraswathi, S., Kumaran, R.S., and Marthi, G. (2023). Intelligent Edge Computing for Cyber Physical Applications, Elsevier.
12. Mustra, M., Delac, K., and Grgic, M. (2008, January 10–12). Overview of the DICOM standard. Proceedings of the 2008 50th International Symposium ELMAR, Zadar, Croatia.
13. Fennell, N., Ralston, M.D., and Coleman, R.M. (2021). Practical Imaging Informatics: Foundations and Applications for Medical Imaging, Springer.
14. Cooke, R.E., Gaeta, M.G., Kaufman, D.M., and Henrici, J.G. (2003). Picture Archiving and Communication System. (6,574,629), U.S. Patent.
15. DICOM images have been hacked! Now what?10.2214/AJR.19.21958 ↗
16. How secure is your radiology department? Mapping digital radiology adoption and security worldwide10.2214/AJR.15.15283 ↗
17. Beek, C. (2023, September 05). Mcafee Researchers Find Poor Security Exposes Medical Data to Cybercriminals. Available online: https://www.mcafee.com/blogs/other-blogs/mcafee-labs/mcafee-researchers-find-poor-security-exposes-medical-data-to-cybercriminals/.
18. Oliveira, P.A.M., Junior, E.C., Andrade, R.M., Santos, I.S., and Neto, P.A.S. (2022). Ten Years of eHealth Discussions on Stack Overflow.10.5220/0010801000003123 ↗
19. A qualitative analysis of the needs and experiences of hospital-based clinicians when accessing medical imaging10.1007/s10278-021-00446-1 ↗
20. Cybersecurity in PACS and medical imaging: An overview10.1007/s10278-020-00393-3 ↗
21. Integrated cybersecurity methodology and supporting tools for healthcare operational information systems10.1016/j.cose.2023.103189 ↗
22. Kumar, P., Singh, A., and Sengupta, A. (2022). Cyber Security in Intelligent Computing and Communications, Springer.
23. Wang, Z., Li, Q., Wang, Y., Liu, B., Zhang, J., and Liu, Q. (2019, January 11–15). Medical protocol security: DICOM vulnerability mining based on fuzzing technology. Proceedings of the 2019 ACM SIGSAC Conference on Computer and Communications Security, London, UK.10.1145/3319535.3363253 ↗
24. Wang, Z., Li, Q., Liu, Q., Liu, B., Zhang, J., Yang, T., and Liu, Q. (December, January 29). DICOM-Fuzzer: Research on DICOM vulnerability mining based on Fuzzing technology. Proceedings of the Communications and Networking: 14th EAI International Conference, ChinaCom 2019, Shanghai, China.10.1007/978-3-030-41114-5_38 ↗
25. Digitization of healthcare sector: A study on privacy and security concerns10.1016/j.icte.2023.02.007 ↗
26. Big data security and privacy in healthcare: A Review10.1016/j.procs.2017.08.292 ↗
27. (2023, July 08). GitHub-ionianCTF/dicom_simulation: A DICOM Simulator in Python Sending “.dcm” Files from a Local Folder to a PACS Server Using Pynetdicom and Pydicom.—Github.com. Available online: https://github.com/ionianCTF/dicom_simulation.
28. Educational RIS/PACS simulator. In Proceedings of the Medical Imaging 2003: PACS and Integrated Medical Information Systems: Design and Evaluation
29. (2023, July 08). Orthanc—DICOM Server—Orthanc-Server.com. Available online: https://www.orthanc-server.com/.
30. (2023, July 08). Onis Viewer—Dicom Viewer and PACS—Onis-Viewer.com. Available online: https://onis-viewer.com.
31. Learning HL7 FHIR using the HAPI FHIR server and its use in medical imaging with the SIIM dataset10.1007/s10278-018-0090-y ↗
32. Mastering DICOM with DVTk10.1007/s10278-007-9057-0 ↗
33. (2023, July 08). DVTK/RIS_Emulator at Master·151706061/DVTK—Github.com. Available online: https://github.com/151706061/DVTK/tree/master/RIS_Emulator.
34. Piraino, D. (2001). Digital(r) Evolution in Radiology, Springer.
35. Oemig, F., Snelick, R., Oemig, F., and Snelick, R. (2016). Testing Tools. Healthcare Interoperability Standards Compliance Handbook: Conformance and Testing of Healthcare Data Exchange Standards, Springer.10.1007/978-3-319-44839-8 ↗
36. (2023, July 08). GitHub—Hapifhir/hapi-hl7v2—Github.com. Available online: https://github.com/hapifhir/hapi-hl7v2.
37. DICOM integration libraries for medical image interoperability: A technical review10.1109/RBME.2020.3042642 ↗
38. Cawthra, J., Hodges, B., Kuruvilla, J., Littlefield, K., Niemeyer, B., Peloquin, C., Wang, S., Williams, R., and Zheng, K. (2019). Securing Picture Archiving and Communication System (PACS) Cybersecurity for the Healthcare Sector, Nist Special Publication.10.6028/NIST.SP.1800-24 ↗
39. Mileva, A., Velinov, A., Dimitrova, V., Caviglione, L., and Wendzel, S. (2022). Information hiding in the dicom message service and upper layer service with entropy-based detection. Entropy, 24.10.3390/e24020176 ↗
40. Fritz, S.L., Roys, S.R., and Munjal, S. (1996, January 13–15). Design requirements for DICOM patient, study, and results management. Proceedings of the Medical Imaging 1996: PACS Design and Evaluation: Engineering and Clinical Issues, Newport Beach, CA, USA.10.1117/12.239237 ↗
41. (2023, July 08). Welcome to the Orthanc Book 2014; Orthanc Book Documentation—Book.Orthanc-Server.com. Available online: https://book.orthanc-server.com/index.html.
42. Association, N.E.M. (2023, September 05). Digital Imaging and Communication in Medicine (DICOM). NEMA PS 3 Supplement 23 Structured Reporting. Available online: https://www.dicomstandard.org/current.
43. Hamamoto, K. (1999, January 5–8). Standardization of JPEG quantization table for medical ultrasonic echo images. Proceedings of the ICECS’99. Proceedings of ICECS’99. 6th IEEE International Conference on Electronics, Circuits and Systems (Cat. No. 99EX357), Paphos, Cyprus.
44. (2023, August 24). Security—Dicomstandard.org. Available online: https://www.dicomstandard.org/using/security.
45. (2023, July 08). GitHub—Pydicom/Pynetdicom: A Python Implementation of the DICOM Networking Protocol—Github.com. Available online: https://github.com/pydicom/pynetdicom.
46. (2023, July 08). GitHub—Pydicom/Pydicom: Read, Modify and Write DICOM files with Python Code—Github.com. Available online: https://github.com/pydicom/pydicom.
47. (2023, August 22). Docker—Github.com. Available online: https://github.com/docker.
48. Frenz, C. (2023, July 08). OWASP Secure Medical Device Deployment Standard Version 2.0. Available online: https://owasp.org/www-pdf-archive/OWASP_Secure_Medical_Devices_Deployment_Standard_7.18.18.pdf.
49. (2023, August 22). DICOM Security—Sdnewhop/Dicom:—Github.com. Available online: https://github.com/sdnewhop/dicom.
50. (2023, August 22). Dicom-Brute NSE Script 2014; Nmap Scripting Engine Documentation—Nmap.org. Available online: https://nmap.org/nsedoc/scripts/dicom-brute.html.
51. (2023, August 22). Dicom-Ping NSE Script 2014; Nmap Scripting Engine Documentation—Nmap.org. Available online: https://nmap.org/nsedoc/scripts/dicom-ping.html.
52. (2023, August 22). Mitigations—Enterprise|MITRE ATT&CK—Attack.mitre.org. Available online: https://attack.mitre.org/mitigations/enterprise/.