A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> Because of the importance of the security issues in the management of medical information, we suggest the use of watermarking techniques to complete the existing measures for protecting medical images. We discuss the necessary requirements for such a system to be accepted by medical staff and its complementary role with respect with existing security systems. We present different scenarios, one devoted to the authentication and tracing of the images, the second to the integrity control of the patient's record. <s> BIB001 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> The control of the integrity and authentication of medical images is becoming ever more important within the Medical Information Systems (MIS). The intra- and interhospital exchange of images, such as in the PACS (Picture Archiving and Communication Systems), and the ease of copying, manipulation and distribution of images have brought forth the security aspects. In this paper we focus on the role of watermarking for MIS security and address the problem of integrity control of medical images. We discuss alternative schemes to extract verification signatures and compare their tamper detection performance. <s> BIB002 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> Medical image security is an important issue when digital images and their pertinent patient information are transmitted across public networks. Mandates for ensuring health data security have been issued by the federal government such as Health Insurance Portability and Accountability Act (HIPAA), where healthcare institutions are obliged to take appropriate measures to ensure that patient information is only provided to people who have a professional need. Guidelines, such as digital imaging and communication in medicine (DICOM) standards that deal with security issues, continue to be published by organizing bodies in healthcare. However, there are many differences in implementation especially for an integrated system like picture archiving and communication system (PACS), and the infrastructure to deploy these security standards is often lacking. Over the past 6 years, members in the Image Processing and Informatics Laboratory, Childrens Hospital, Los Angeles/University of Southern California, have actively researched image security issues related to PACS and teleradiology. The paper summarizes our previous work and presents an approach to further research on the digital envelope (DE) concept that provides image integrity and security assurance in addition to conventional network security protection. The DE, including the digital signature (DS) of the image as well as encrypted patient information from the DICOM image header, can be embedded in the background area of the image as an invisible permanent watermark. The paper outlines the systematic development, evaluation and deployment of the DE method in a PACS environment. We have also proposed a dedicated PACS security server that will act as an image authority to check and certify the image origin and integrity upon request by a user, and meanwhile act also as a secure DICOM gateway to the outside connections and a PACS operation monitor for HIPAA supporting information. <s> BIB003 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> Recently, the medical image has been digitized by the development of computer science and digitization of the medical devices. There are needs for database service of the medical image and long term storage because of the construction of PACS (Picture Archiving and Communication System) following DICOM (Digital Imaging Communications in Medicine) standards, telemedicine, and et al. Furthermore, authentication and copyright protection are required to protect the illegal distortion and reproduction of the medical information data. In this paper, we propose digital watermarking technique for medical image that prevents illegal forgery that can be caused after transmitting medical image data remotely. A wrong diagnosis may be occurred if the watermark is embedded into the whole area of image. Therefore, we embed the watermark into some area of medical image, except the decision area that makes a diagnosis so called region of interest (ROI) area in our paper, to increase invisibility. The watermark is the value of bit-plane in wavelet transform of the decision area for certification method of integrity verification. The experimental results show that the watermark embedded by the proposed algorithm can survive successfully in image processing operations such as JPEG lossy compression. <s> BIB004 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> In this paper, we present an efficient and effective digital watermarking method for image tamper detection and recovery. Our method is efficient as it only uses simple operations such as parity check and comparison between average intensities. It is effective because the detection is based on a hierarchical structure so that the accuracy of tamper localization can be ensured. That is, if a tampered block is not detected in level-1 inspection, it will be detected in level-2 or level-3 inspection with a probability of nearly 1. Our method is also very storage effective, as it only requires a secret key and a public chaotic mixing algorithm to recover a tampered image. The experimental results demonstrate that the precision of tamper detection and localization is 99.6% and 100% after level-2 and level-3 inspection, respectively. The tamper recovery rate is better than 93% for a less than half tampered image. As compared with the method in Celik et al. [IEEE Trans. Image Process. 11(6) (2002) 585], our method is not only as simple and as effective in tamper detection and localization, it also provides with the capability of tamper recovery by trading off the quality of the watermarked images about 5dB. <s> BIB005 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> Digital audio, video, images, and documents are flying through cyberspace to their respective owners. Unfortunately, along the way, individuals may choose to intervene and take this content for themselves. Digital watermarking and steganography technology greatly reduces the instances of this by limiting or eliminating the ability of third parties to decipher the content that he has taken. The many techiniques of digital watermarking (embedding a code) and steganography (hiding information) continue to evolve as applications that necessitate them do the same. The authors of this second edition provide an update on the framework for applying these techniques that they provided researchers and professionals in the first well-received edition. Steganography and steganalysis (the art of detecting hidden information) have been added to a robust treatment of digital watermarking, as many in each field research and deal with the other. New material includes watermarking with side information, QIM, and dirty-paper codes. The revision and inclusion of new material by these influential authors has created a must-own book for anyone in this profession. ::: ::: *This new edition now contains essential information on steganalysis and steganography ::: *New concepts and new applications including QIM introduced ::: *Digital watermark embedding is given a complete update with new processes and applications <s> BIB006 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> This paper presents a novel algorithm to successfully achieve viable integrity and authenticity addition and verification of n-frame DICOM medical images using cryptographic mechanisms. The aim of this work is the enhancement of DICOM security measures, especially for multiframe images. Current approaches have limitations that should be properly addressed for improved security. The algorithm proposed in this work uses data encryption to provide integrity and authenticity, along with digital signature. Relevant header data and digital signature are used as inputs to cipher the image. Therefore, one can only retrieve the original data if and only if the images and the inputs are correct. The encryption process itself is a cascading scheme, where a frame is ciphered with data related to the previous frames, generating also additional data on image integrity and authenticity. Decryption is similar to encryption, featuring also the standard security verification of the image. The implementation was done in JAVA, and a performance evaluation was carried out comparing the speed of the algorithm with other existing approaches. The evaluation showed a good performance of the algorithm, which is an encouraging result to use it in a real environment. <s> BIB007 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> In a recent paper presented by Lin et al., a block-based hierarchical watermarking algorithm for digital images is proposed. It adopts parity check and the intensity-relation check to conduct the experiment of image tamper detection. Their experimental results indicate that the precision of tamper detection and localization is 99.6% and 100% after level-2 and level-3 inspections, respectively. The proposed attacks demonstrate that this watermarking algorithm is fundamentally flawed in that the attacker can tamper a watermarked image easily without being detected. In this paper, a four-scanning attack aimed to Lin et al.'s watermarking method is presented to create tampered images. Furthermore, in case they use encryption to protect their 3-tuple-watermark, we proposed a blind attack to tamper watermarked images without being detected. Experimental results are given to support and enhance our conclusions, and demonstrate that our attacks are successful in tampering watermarked images. <s> BIB008 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act (ARRA) of 2009 [1] include a provision commonly referred to as the “Health Information Technology for Economic and Clinical Health Act” or “HITECH Act” that is intended to promote the electronic exchange of health information to improve the quality of health care. Subtitle D of the HITECH Act includes key amendments to strengthen the privacy and security regulations issued under the Health Insurance Portability and Accountability Act (HIPAA). The HITECH act also states that “the National Coordinator” must consult with the National Institute of Standards and Technology (NIST) in determining what standards are to be applied and enforced for compliance with HIPAA. This has led to speculation that NIST will recommend that the government impose the Federal Information Security Management Act (FISMA) [2], which was created by NIST for application within the federal government, as requirements to the public Electronic Health Records (EHR) community in the USA. In this paper we will describe potential impacts of FISMA on medical image sharing strategies such as teleradiology and outline how a strict application of FISMA or FISMA-based regulations could have significant negative impacts on information sharing between care providers. <s> BIB009 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> Authenticating medical images using watermarking techniques has become a very popular area of research, and some works in this area have been reported worldwide recently. Besides authentication, many data-hiding techniques have been proposed to conceal patient’s data into medical images aiming to reduce the cost needed to store data and the time needed to transmit data when required. In this paper, we present a new hybrid watermarking scheme for DICOM images. In our scheme, two well-known techniques are combined to gain the advantages of both and fulfill the requirements of authentication and data hiding. The scheme divides the images into two parts, the region of interest (ROI) and the region of non-interest (RONI). Patient’s data are embedded into ROI using a reversible technique based on difference expansion, while tamper detection and recovery data are embedded into RONI using a robust technique based on discrete wavelet transform. The experimental results show the ability of hiding patient’s data with a very good visual quality, while ROI, the most important area for diagnosis, is retrieved exactly at the receiver side. The scheme also shows some robustness against certain levels of salt and pepper and cropping noise. <s> BIB010 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> Medical image is usually comprised of region of interest (ROI) and region of non interest (RONI). ROI is the region that contains the important information from diagnosis point of view so it must be stored without any distortion. We have proposed a digital watermarking technique which avoids the distortion of image in ROI by embedding the watermark information in RONI. The watermark is comprised of patient information, hospital logo and message authentication code, computed using hash function. Earlier BCH encryption of watermark is performed to ensure inaccessibility of embedded data to the adversaries. <s> BIB011 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> Teleradiology is probably the most successful eHealth service available today. Its business model is based on the remote transmission of radiological images (e.g. X-ray and CT-images) over electronic networks, and on the interpretation of the transmitted images for diagnostic purpose. Two basic service models are commonly used teleradiology today. The most common approach is based on the message paradigm (off-line model), but more developed teleradiology systems are based on the interactive use of PACS/RIS systems. Modern teleradiology is also more and more cross-organisational or even cross-border service between service providers having different jurisdictions and security policies. This paper defines the requirements needed to make different teleradiology models trusted. Those requirements include a common security policy that covers all partners and entities, common security and privacy protection principles and requirements, controlled contracts between partners, and the use of security controls and tools that supporting the common security policy. The security and privacy protection of any teleradiology system must be planned in advance, and the necessary security and privacy enhancing tools should be selected (e.g. strong authentication, data encryption, non-repudiation services and audit-logs) based on the risk analysis and requirements set by the legislation. In any case the teleradiology system should fulfil ethical and regulatory requirements. Certification of the whole teleradiology service system including security and privacy is also proposed. In the future, teleradiology services will be an integrated part of pervasive eHealth. Security requirements for this environment including dynamic and context aware security services are also discussed in this paper. <s> BIB012 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> Teleradiology applications and universal availability of patient records using web-based technology are rapidly gaining importance. Consequently, digital medical image security has become an important issue when images and their pertinent patient information are transmitted across public networks, such as the Internet. Health mandates such as the Health Insurance Portability and Accountability Act require healthcare providers to adhere to security measures in order to protect sensitive patient information. This paper presents a fully reversible, dual-layer watermarking scheme with tamper detection capability for medical images. The scheme utilizes concepts of public-key cryptography and reversible data-hiding technique. The scheme was tested using medical images in DICOM format. The results show that the scheme is able to ensure image authenticity and integrity, and to locate tampered regions in the images. <s> BIB013 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> This research paper discussed the usage of watermarking in medical images to ensure the authenticity and integrity of the image and reviewed some watermarking schemes that had been developed. A design of a reversible tamper detection and recovery watermarking scheme was then proposed. The watermarking scheme uses a 640x480x8 bits ultrasound grayscale image as a sample. The concept of ROI (Region Of Interest) and RONI (Region Of Non Interest) were applied. Watermark embedded can be used to detect tampering and recovery of the image can be done. The watermark is also reversible. <s> BIB014 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> In this article, a new fragile, blind, high payload capacity, ROI (Region of Interest) preserving Medical image watermarking (MIW) technique in the spatial domain for gray scale medical images is proposed. We present a watermarking scheme that combines lossless data compression and encryption technique in application to medical images. The effectiveness of the proposed scheme, proven through experiments on various medical images through various image quality measure matrices such as PSNR, MSE and MSSIM enables us to argue that, the method will help to maintain Electronic Patient Report(EPR)/DICOM data privacy and medical image integrity. <s> BIB015 </s> A Review of Medical Image Watermarking Requirements for Teleradiology <s> Introduction <s> Medical image data require strict security, confidentiality and integrity. To achieve these stringent requirements, we propose a hybrid watermarking method which embeds a robust watermark in the region of non-interest (RONI) for achieving security and confidentiality, while integrity control is achieved by inserting a fragile watermark into the region of the interest (ROI). First the information to be modified in ROI is separated and is inserted into RONI, which later is used in recovery of the original ROI. Secondly, to avoid the underflow and overflow, a location map is generated for embedding the watermark block-wise by leaving the suspected blocks. This avoids the preprocessing step of histogram modification. The image visual quality, as well as tamper localization, is evaluated. We use weighted peak signal to noise ratio for measuring image quality of watermarked images. Experimental results show that the proposed method outperforms the existing hybrid watermarking techniques. <s> BIB016
Recent technological advances introduced a radical change in the modern health care sector including medical imaging facilities, hospital information system (HIS), and information management systems in hospitals. Changes in medical imaging facilities in radiology have acquired sufficient reliability and cost-effectiveness that the film-based imaging technology has been shifted to filmless techniques for producing digital images on various devices rather than generating hardcopies. With the use of these digital medical images, in addition, HIS comprising radiology information system (RIS) and picture archiving and communication system (PACS) BIB004 has facilitated offering various eHealth services. These eHealth services are introducing new practices for the profession as well as for the patients by enabling remote access, transmission, and interpretation of the medical images for diagnosis purposes. This has made easy the widespread use of teleradiology with the potential to improve healthcare access, delivery, and standards, where complex and new legal and ethical issues are also raising. These issues include image retention and fraud, privacy, malpractice liability, licensing and credentialing, and contracts for PACS, RIS, and teleradiology  . In teleradiology, one of the most successful eHealth services at present, security and privacy protection has become a critical issue BIB012 BIB009 . In this study, we mainly focus on the teleradiology that essentially captures a broad range of security requirements along with other radiological information management issues including that of its original medical specialty, radiology. When radiology employs the use of imaging to both diagnose and treat disease visualized within the human body, teleradiology has been for a long time understood to be an eHealth service done through remote transmission of the radiology images and information over electronic networks, and the interpretation of the transmitted images for diagnosis purposes BIB012 . Remote access and transmission of the images and other radiology information, particularly, electronic personal health information (EPHI), expose them to possible tampering or theft with serious ramifications, since they are sensitive and in most cases EPHI are identifiable. Such radiology images and information not only require protection with integrity and high confidentiality but also appropriate management through different healthcare services. Providing the required security and privacy of the radiology information requires the following: (1) a standard set of security and privacy profile/policy for teleradiology and (2) a set of security measures by which the security principles in the profile are fulfilled. Various national and international legislative rules and directives define the security and privacy requirements of medical information. These requirements are being achieved by different conventional measures, which are thought to be incapable of providing the required security of the electronic radiology information in the PACS/RIS-based teleradiology BIB007 BIB003 BIB001 . On the other hand, recent studies show the possibility of using digital watermarking for improving security in teleradiology BIB013 BIB016 BIB005 BIB008 BIB010 BIB011 BIB014 BIB015  . Digital watermarking has various attractive properties to complement the existing security measures that can offer better protection for various multimedia applications BIB006 . However, it is particularly important to know the applicability of digital watermarking from every aspect of radiology information requirements and the suitability of that over other (both the existing and developing) similar measures. Although Coatrieux et al. BIB001 BIB002 studied the applicability of digital watermarking in medical imaging, a further justification of the watermarking considering the security requirements in teleradiology is still necessary. The rest of the paper is organized as follows. General security and privacy requirements of, and expected threats for, the medical information from the perspective of different security and privacy profiles/policies are reviewed and presented in section "Security and Privacy Requirements in Teleradiology." The limitations of the conventional security measures to handle those threats are also studied and discussed there in. The section on "Digital Watermarking in Teleradiology" introduces briefly the digital watermarking and its various benefits. Justification over other comparable measures, various properties, objectives, suitable types, and their requirements of watermarking for medical images are also given. Concluding remarks and discussion are given in the section on "Discussion and Conclusions."