The DICOM 2014 Chengdu workshop focused on securing DICOM by addressing data security, integrity, and availability, emphasizing the risks of compromised security such as data loss and fraud. It outlined various security profiles, user authentication methods, and auditing procedures while highlighting the importance of encryption and access control measures in protecting DICOM data during transmission and at rest. The workshop concluded with recommendations for implementing security best practices and ensuring ongoing consideration of security throughout project lifecycles.

1. THE DICOM 2014 Chengdu Workshop
August 25, 2014 Chengdu, China
Keeping It Safe
Securing DICOM
Brad Genereaux, Agfa HealthCare
Product Manager
Industry Co-Chair, DICOM WG-27, Web Technologies

2. What is security?
• Protecting data security (against
unauthorized access)
• Protecting data integrity (against
unauthorized changes)
• Protecting data loss (against
unauthorized deletions)
• Protecting data availability (against
denial of service)

3. What are the implications if
security is compromised?
• Data corruption and loss
• Fraud against those victimized
• Civil penalties (fines and lawsuits)
• Criminal penalties
• Serious harm and death

4. What is NOT security?
• Changing names of parameters,
servers or functions to make it harder
to guess
• Including dangerous functions in a
release but not including them in
documentation

5. Keeping DICOM Safe
DICOM
DICOM
Simple workflow
•Modality transmits images to archive
•Radiologist requests images for reading
: Out to cause security issues
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 6

6. DICOM Security Profiles
• Defined in PS3.15, “Security and
System Management Profiles”
• Describes methods to mitigate various
security concerns
• Items in red describe solutions that are
used in the industry but not explicity
part of the DICOM standard
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 7

7. DICOM in Transit
DICOM
DICOM
Who sees this image?
• The modality, who sends the image
• The archive, who receives the image
• Anyone on the network between
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 8

8. DICOM-TLS
DICOM
DICOM
• Transport Level Security encryption (defined
in PS3.15 Section B.1)
• Encryption is negotiated as part of TLS
• Traffic encrypted with public certificate and
decrypted by private key
• Network VPN tunnels is another mechanism
• DICOMweb can leverage HTTPS (TLS based)
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 9

9. DICOM in Transit
DICOM
DICOM
Who are the actors in transmission?
• The modality, who sends the image
• The archive, who receives the image
• Anyone pretending to be these actors
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 10

10. Node Identity
DICOM
DICOM
• DICOM-TLS certificates specifies
identifying information about the
owner
• Verification of certificates are done
against a signing authority
• AE titles are a less secure alternative
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 11

11. User Authentication
DICOM
DICOM
Who can retrieve images?
• Device is validated by DICOM-TLS
• User can retrieve images
• Anyone else using device can, too
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 12

12. User Authentication
DICOM
DICOM
• Defined in PS3.15 B.4-7
• Authentication of users can occur via
• Mutual TLS authentication (each side presents certificates)
• Authentication during association negotiation (SAML,
Kerberos, etc)
• Authenticating users at the application level and
making trusted calls to the imaging backend is an
alternative approach
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 13

13. Auditing
• Described in PS 3.15 Part A.5
• User should be known
• Events for authentication, query,
access, transfer, import/export, and
deletion
• This is used in the IHE ITI ATNA profile
with Radiology option
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 14

14. DICOM at Rest
DICOM
DICOM
Who ensures the images are genuine as
the modality provides them?
• The archive accomplishes this task
• Anyone else who can manipulate the
archive
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 15

15. Digital Signatures
DICOM
DICOM
• DICOM supports digital signatures which provides
integrity check and other features
• Defined in PS3.15 Section C
• Individual fields can also be selectively encrypted
• Disk-level encryption can also be used to maintain
integrity at rest
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 16

16. Media Storage
• Used when DICOM is transmitted via
physical media (CD, DVD, USB key)
• Guarantees confidentiality, integrity,
and media origin
• Defined in PS3.15 section D
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 17

17. Anonymization
• Anonymization profiles exist to
support masking of data for various
purposes
• Clinical trials
• Teaching files
• Defined in PS3.15 section E
• Addresses removal and replacement of
DICOM attributes that may reveal
protected health information
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 18

18. DICOM’s Stance
• DICOM enables a very wide variety of
authentication and access control
policies, but does not mandate them
• DICOMweb shares the same position
through the use of standard internet
technologies
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 19

19. Suggestions
 Use DICOM-TLS, and HTTPS for DICOMweb
 Use appropriate authentication and
authorization measures
 Use appropriate at-rest encryption
mechanisms
 Control access via managed environments,
strong identity management, firewalls
 Consider security throughout your project
lifecycle, not at the end
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 20

20. Keep It Safe!
DICOM
Questions? Thank you!
DICOM
August 2014, THE DICOM 2014 Chengdu Workshop Keeping It Safe – Brad Genereaux 21