Are DICOM Viewers Creating Security Risks in Hospitals?
Medical imaging technology relies on the DICOM standard to store, view, and share scans like X-rays, MRIs, and CTs.
DICOM viewers online allow doctors convenient access to these
images through web browsers.
However,
the WADO to STOW transition process in these viewers may unintentionally reduce
security.
We'll
break down how hackers could leverage these DICOM transitions to infiltrate
hospital systems.
Understanding
WADO and STOW
First,
let’s define the DICOM protocols involved:
● WADO:
Web Access to DICOM Objects retrieves DICOM images, data, etc., from PACS
through HTTP requests.
● STOW:
DICOM Storage commits directly to PACS storage.
WADO
allows web access without exposure to the backend. STOW enables writing data
straight into storage.
The Problem
Most
DICOM viewers utilize both protocols. Images are fetched with WADO and then
converted into STOW for display and manipulation. This transition opens a
doorway that hackers could exploit.
Attack
Vectors Introduced
The
WADO to STOW workflow likely introduces security holes in these key areas:
SQL Injection
Converting
the pixel data may allow SQL injection attacks on the PACS database by
including malicious SQL statements.
This
could let attackers:
● Steal patient health information
● Corrupt/delete images and records
● Install malware for further access
Cross-Site Scripting (XSS)
Attackers
may also leverage XSS vulnerabilities opened up by direct STOW access. This
allows them to run malicious scripts and code snippets in the viewer.
Effects
of an XSS attack include:
● Hijacking user sessions
● Installing trojans
● Crashing applications
DDOS
The
additional server load required for STOW transactions could facilitate DDOS
attacks aimed at overloading systems and forcing downtime.
Data Theft/Manipulation
Finally, unchecked write access enables the theft or manipulation of patient images and
information. The impacts range from falsified records to stolen identities.
Minimizing
the Risks
While
closing these holes entirely within viewers may not be possible, developers can
implement controls to reduce the risks, including:
● Input validation - Filter all inputs into the viewer
● Output encoding - Encode data sent to browsers
● Access restrictions - Limit viewer permissions
● Encryption - Encrypt network traffic end-to-end
● Monitoring - Detect unauthorized changes
Following security best practices tailored for DICOM and medical environments also minimizes exposure.
The
Bottom Line
DICOM
web viewers provide indispensable, easy access to medical imaging. However, the
workflow allowing this convenience likely introduces security holes in hospital
networks.
Developers
must prioritize securing these applications to protect patient health
information and prevent disruptions of critical systems. Information security
teams should also add DICOM viewers to their audit plans.
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