# Cybersecurity and Medical Imaging: A Simulation-Based Approach to DICOM Communication
## 5 Simulation Results and Analysis
### Setting Up Orthanc to Accept Data from the Modality Simulator
\begin{table}
\begin{tabular}{p{142.3 pt} p{142.3 pt} p{142.3 pt}} \hline
**MITRE ID** & **Mitigation Action** & **Realization and Relevance to DICOM** \\ \hline M1047 & Perform audits or scans to identify weaknesses. & Regularly audit DICOM systems, configurations, and permissions to identify potential vulnerabilities that could impact DICOM communication. \\ \hline M0804 & Require user authentication. & Implement strong user authentication mechanisms before granting access to DICOM data or devices to prevent unauthorized access or data manipulation. \\ \hline M1041 & Encrypt Sensitive Information. & Apply strong encryption to sensitive DICOM data to ensure its confidentiality during transmission and storage. \\ \hline M1051 & Update Software. & Regularly update DICOM software components to patch vulnerabilities and reduce the risk of exploitation during communication. \\ \hline M1017 & User Training. & Train users involved in DICOM communication to recognize and respond to potential access or manipulation attempts, such as spearphishing or social engineering attacks. \\ \hline M0930 & Network Segmentation. & Segment the network to isolate critical DICOM systems from other network segments, preventing unauthorized access and protecting DICOM communication from potential threats. \\ \hline M0931 & Network Intrusion Prevention. & Use intrusion detection techniques that don’t disrupt real-time DICOM communication protocols to identify and block unauthorized or malicious network traffic. \\ \hline M1037 & Limit Access to Resources Over Network. & Restrict network access to DICOM file shares and remote access points, reducing exposure to potential attackers and ensuring secure communication. \\ \hline M1035 & Filter Network Traffic. & Utilize network appliances and endpoint software to filter incoming and outgoing DICOM network traffic, blocking potentially harmful or unauthorized data flows. \\ \hline \end{tabular}
\end{table} 
Table 2: MITRE Mitigation Actions and Relevance to DICOM. ## 6 Conclusions

In this research, a DICOM simulator incorporating advanced features of virtualized environments and cloud computing was developed within a virtual lab context. The focus of this study was on conducting in-depth analyses and facilitating learning related to the fundamental attributes of the DICOM protocol. The DICOM simulator provides a flexible approach that can be further developed and customized to meet the specific needs of researchers. By utilizing cloud computing capabilities, the simulator can emulate complex scenarios and facilitate interoperability between different systems and devices. This enables researchers to explore and experiment with various aspects of DICOM communication and PACS integration. Moreover, the simulation has the capability to produce network traffic through the utilization of the DICOM protocol. This traffic generation results in the creation of authentic datasets, which can be effectively employed for the advancement of machine learning, deep learning technologies, and anomaly detection techniques. The presented topology and deployment can serve as a platform for conducting security control testing, allowing researchers to evaluate the robustness of security measures, identify vulnerabilities, and test different security configurations in a controlled and safe environment. In this way, it provides researchers with an opportunity to gain a comprehensive understanding of DICOM communication and its practical implementation. A significant future milestone involves fostering enhanced interoperability between PACS while encompassing other medical imaging devices or formats. This expanded interoperability can facilitate seamless communication and data exchange across various SOP classes, extending the simulation support to encompass a wider range of scenarios and medical imaging modalities. Moreover, an area of promising exploration is the extension of research in the development and utilization of digital twins for medical imaging modalities.