In a previous post I talked about Media Security and Encrypted DICOM CDs, and this topic has also come up on Aunt Minnie. Whilst there has been a general concern that the threat to privacy is small and the risk to usability high, it seems that in the UK at least, this discussion has been pre-empted by a decision by the NHS to require encryption, outlined in a letter from the NHS Chief Executive, David Nicholson. I quote from this letter:
- "You are aware that there is a mandatory requirement that all removable data, including laptops, CDs, USB Pens etc must be encrypted."
- "The encryption mandate applies equally to PACS images whether on CD or back-up tapes."
- "There could be occasional exceptions on patient safety grounds ..."
- "The CD and the password MUST be transferred by different routes."
Regardless, it would seem that the writing is on the wall for encryption of DICOM media, and solutions will need to be provided, even though the inconvenience and risk to patient safety will likely be significant. Accordingly, we have been considering a number of strategies to address this need, specifically, the encryption of an entire set of files (or an entire device), such as the open-source cross-platform TrueCrypt approach, or the encryption of individual files, such as by using the Cryptographic Message Syntax (CMS) that was designed for secure email (S/MIME) and which is already included in the DICOM standard for secure media. Further, one needs to make a choice between a password-based mechanism (so-called Password Based Encryption (PBE)), or a scheme that depends on the use of public keys and certificates and so forth, dependent on there being a Public Key Infrastructure (PKI) for senders and recipients.
The primary advantage of encrypting the entire file set or device would seem to be that one could do that, then present the encrypted set as if it were an ordinary filesystem, and the effect would be completely transparent to applications like DICOM viewers and PACS importers, once the decryption had been activated by the user entering a password or the appropriate private key being matched. Unfortunately, great as this sounds, it turns out that one needs to install some software into the operating system (like a device driver) to actually make this happen, and this requires administrative privileges. Either recipients need to have software pre-installed on their machine by someone appropriately authorized, or they need to have the right to do this themselves, for example when auto-running such a tool from the media itself. The latter is indeed supported by TrueCrypt, for example, but how likely is it that the average doctor receiving media will have such privileges, and how safe would it be (in terms of the risk of viruses) to allow them to do so ? This may be a showstopper for what otherwise seems on the face of it like the most expedient solution. There is also the matter that TrueCrypt is not a standard per se, nor is it included in other standards like DICOM, but the latter could easily be rectified since the format is fully documented and free from intellectual property restrictions.
By contrast, what seems like a more complex approach, inclusion of support for encryption directly into the DICOM viewing or importing software, may actually be a more effective solution, since it requires no additional permissions or privileges on the part of the user. Since often a viewer is supplied on the media anyway, that viewer can support the encryption mechanism used for the files. As long as the encryption scheme is a standard one, then other software can also view or import the media, if that other software also supports the standard scheme. In the interim, whilst other viewers and importers are being "upgraded" to support encryption, one could add to the on-board viewer the capability to not only decrypt and view the files, but also to send the decrypted images over a DICOM network to a PACS or workstation (preferrably allowing editing of the Patient ID field to allow for reconciliation of different sites identifiers in the process).
As mentioned, DICOM already defines the use of CMS for this purpose for secure media, though to my knowledge this feature has never been implemented in a commercial product. Further, in anticipation of this need we have been working on adding a standard password-based mechanism to augment the public-key approach used in the existing standard, specifically in DICOM CP 895, so that now we have the option of using either PBE or a PKI as the situation warrants. There are free and open-source encryption libraries that have support for CMS as well as the underlying encryption schemes like AES, for example the excellent Bouncy Castle libraries, and I and others have begun work on testing this concept using these libraries. Indeed, you can download from here a small test dataset that I created encrypted using the DICOM Secure Media profile using the CP 895 mechanism.
Regardless of which technical approach prevails, in all likelihood the simpler password-based mechanisms will likely be deployed, if only because of the complete lack of an existing PKI in most health care environments. Obviously, the privacy protection from encryption is only as good as the password chosen. Though security folks talk about long and complex passwords and phrases to improve protection, one does have to wonder how in reality imaging centers will choose passwords, and to what extent they will be based on well-known information that is memorable and predictable to simplify use, balanced against the relatively low perceived likelihood and consequences of a security breach. Further, there has yet to be discussion on good security practices and procedures for exchanging the media and the passwords separately, and what the recipient should do in this regard. For example, should the password be included in the printed report that is faxed or email to the intended recipient ? Should the patient have a copy of this for their long term use ? I would certainly expect so, but inevitably the patient sill store the report with the CD, which rather defeats the point !
None of these mechanisms address the concern that if a password is lost or not transmitted or the recipient cannot for some reason run the on-board viewer, then the patient's safety and convenience are potential at risk. In a network-based scenario, emergency access can be granted on demand, perhaps simply recording an auditable event that such emergency access by an authenticated but otherwise unauthorized individual was granted. With physical media, the sender and recipient are decoupled, however; indeed the recipient may not even be known a priori, such as when a patient takes their images for a second opinion, or for use as priors at a subsequent event. In such cases, loss or lack of access to the password becomes problematic. The problem is exacerbated in regions where it is not traditional for the imaging facility to provide long-term archival of images, such as Australia. One could imaging a scenario in which a woman has her screening mammogram recorded on an encrypted CD, the radiology center does not archive the images, and next year they cannot be used as priors because she has forgotten or lost the password.
Conceivably one could use a more complex form of encryption that allowed for escrow of additional keys that would allow recovery from some central authority perhaps, but such escrow schemes have been widely unpopular in the security community for many reasons. In the absence of an infrastructure to support this, all CDs could include the use of an additional key that was "well known" to some central authority, but of course eventually someone might be able to compromise such a key (consider the DVD Content Scramble System (CSS), for example).
So, though we do not yet have broad consensus on the standard mechanism that the industry should adopt, globally and not just in the UK, we are making some progress. Next week we will be meeting as the IHE Radiology Technical Committee and encryption is one of the topics for discussion for this year's extensions to PDI. The agenda is here, if perhaps you are interested in attending.
Though improving interoperability and reducing the barriers to viewing images on media has always been our primary goal, and encryption has the potential to threaten that objective, hopefully we will have a clear technical direction shortly for those folks who may no longer have the option of avoiding media encryption.