Advances in Medical Image Watermarking: A State of The Art Review

Multimedia Tools and Applications (2024) 83:1407–1447
https://doi.org/10.1007/s11042-023-15396-9
Advances in medical image watermarking: a state of the art

review
Solihah Gull1 · Shabir A. Parah1
Received: 7 January 2022 / Revised: 21 February 2023 / Accepted: 18 April 2023 /

Published online: 5 May 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023
Abstract
Watermarking has been considered to be a potent and persuasive gizmo for its applica-
tion in healthcare setups that work online, especially in the current COVID-19 scenario.
The security and protection of medical image data from various manipulations that take
place over the internet is a topic of concern that needs to be addressed. A detailed review
of security and privacy protection using watermarking has been presented in this paper.
Watermarking of medical images helps in the protection of image content, authentication
of Electronic Patient Record (EPR), and integrity verification. At first, we discuss the vari-
ous prerequisites of medical image watermarking systems, followed by the classification of
Medical Image Watermarking Techniques (MIWT) that include state-of-the-art. We have
classified MIWT’s into four broader classes for providing better understanding of medical
image watermarking. The existing schemes have been presented along with their cons so
that the reader may be able to grasp the shortcomings of the technique in order to develop
novel techniques proving the inevitability of the presented review. Further, various evalua-
tion parameters along with potential challenges pertaining to medical image watermarking
systems have been discussed to provide a deep insight into this research area.
Keywords Electronic Patient Record · Watermarking · Medical Images · Authentication ·

Security
1 Introduction
The emergence of modern technologies including IoT, IoMT, cloud computing, telemed-
icine, and other secluded health setups have overtaken conventional healthcare. Sharing
of digital medical images over the cloud or internet is taking place in huge amounts
resulting in increased active and passive attacks on this data. Manipulation, snooping,
deletion, copying, and other unauthorized access to medical data have increased by
a huge amount [7, 8, 59, 60, 83, 88, 96]. The variation in medical image data along
* Shabir A. Parah
shabireltr@gmail.com
1
Department of Electronics and Instrumentation Technology, University of Kashmir,
Srinagar 190006, India
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1408 Multimedia Tools and Applications (2024) 83:1407–1447
with the patient’s confidential data may lead to adverse effects. Yet there is an alarming
increase in patient information-related thefts, even though it has been enlisted among
the severe crimes. This has led the attention of various researchers towards enhancing
the security of medical images. Various techniques have been developed for the secure
communication of medical images along with the data being hidden within these images
[19, 25, 49]. The main aim is that no person other than the two parties should be able
to extricate the confidential message from the image. For such a purpose various data-
hiding approaches like steganography, cryptography, fingerprinting, and digital water-
marking have been proposed [8, 19, 20, 25, 49, 93]. The pros and cons of these methods
have been presented in Table 1.
Among these methods watermarking is found to be a cogent tool for medical image
watermarking [25]. Watermarking of medical images refers to the hiding of digital
marks that may be either the hospital logo or Electronic Patient Information (EPI) [96].
This logo helps in checking the integrity of the cover image and helps in the recognition
of ownership conflicts. Although image watermarking methods have developed several
years before, still medical image watermarking is found to be more interesting because
of its high applicability in today’s world. A lot of research has been carried out pertain-
ing to watermarking of images yet is medical image watermarking is a new field with
enormous pertinence. Over the years some review papers have been published concern-
ing medical image watermarking. These have been presented in Table 2 and have dif-
ferent applications. Nyeem et al. [54] have presented a review of medical image water-
marking techniques pertaining to security and privacy. Tripathi and Tripathi [87] have
reviewed and compared the various watermarking schemes for applicability to medical
images. It has discussed the various issues with classical watermarking that need to be
considered before implementation in medical images. Qasim et al. [59] have presented
an analysis of various medical image watermarking techniques to evaluate the robust-
ness and precincts of these techniques. Thabit [84] has presented a review of medical
image watermarking techniques specifically pertaining to authenticity verification. The
review papers cited above and in Table 2 have not classified the Medical Image Water-
marking Techniques in a broader spectrum and have just chosen to remain specific to a
particular application. In this review, we have classified the medical image watermark-
ing techniques into four broader classes and have provided the shortcoming of the lit-
erature for the readers to propose novel techniques by overcoming the potential chal-
lenges incurred in the already existing schemes. The earlier existing papers presenting
the review of medical image watermarking techniques have not considered authentica-
tion, integration, and verification, although it is an important domain of medical image
watermarking. Therefore there is a need for the updated review paper so as to fill the
gap and shortage in the already existing literature. This will help the readers to quickly
grasp the idea of existing literature and the shortcomings that need to be worked on
for making the remote and online healthcare system more secure, convenient, and most
importantly reliable.
The rest of the paper is organized as follows. Section 2 presents the prerequisites for
medical image watermarking techniques followed by the general framework of digital
image watermarking in Section 3. Section 4 presents applications of medical image water-
marking techniques while Section 5 presents watermarking techniques for medical images.
Section 6 gives the classification of medical image watermarking techniques based on
domains. Further, Sections 7 and 8 present the State of the art watermarking techniques
for medical images and assessment of watermarked medical images respectively. Section 9
presents the potential issues and challenges while the paper concludes in section 10.
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Table 1 Pros and Cons of Cryptography, Steganography, and Watermarking
Method Pros Cons
Cryptography • Enhances security while transmission and storage of data. • Decryption can be difficult if the key for decrypting
• It encrypts the data itself providing security to it. the data is lost and may require a costly system to
decrypt the data.
• Since the data is in intangible form, the intruders

become suspicious about it.
Steganography • It helps in the protection of the secret data by concealing it into some cover • It provides confidentiality via the use of algorithms, if
like image, audio, or video. the intruder gets to know about the algorithm, it is of
no use.
Watermarking • In watermarking a secret message is hidden in the cover in a way that the differ- • Watermarking does not prevent copying of the content.
ence between the original cover and watermarked cover is indistinguishable.
1409
13
1410
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Table 2 Summary of various review papers for medical image watermarking
Authors Year of Publication Focus of the Review
Nyeem et al. [54] 2013 Applications and requirements of teleradiography

Tripathi and Tripathi [87] 2013 Applications and requirements of medical image watermarking with limited literature
Priya et al. [58] 2014 Specified to Computed Tomography images
Mousavi et al. [50] 2014 Watermarking applications and requirements with review of domain-based watermarking only
Ghazali et al. [23] 2015 Discusses Medical imaging tools and DICOM format with limited literature
Kishore et al. [37] 2016 Presents Robustness of various MIWT’s
Singh [72] 2017 Review of various robust watermarking schemes
Qasim et al. [59] 2018 Discusses watermarking approaches with their application to MIW.
Altaf et al. [3] 2019 Classified watermarking techniques based on domain, perceptivity, and detection methods
Lalan et al. [39] 2020 Focuses mainly on Authentication
Thabit [84] 2021 Authentication based techniques only
Current Review 2023 Broader classification with potential challenges and issues
Limitations of each existing technique
Multimedia Tools and Applications (2024) 83:1407–1447 1411
2 Prerequisites for Medical Image Watermarking Techniques
There are several prerequisites for medical image watermarking. These have been depicted
in Fig. 1.
2.1 Image fidelity
It is a parameter that is used for the calculation of similarity between the original medical
image and watermarked medical image [20, 88, 95]. The watermark should be embedded
in the host medical image in a way that it (watermark) is not perceptible to the Human
Visual System (HVS) and maintains the quality of the host image. This indicates that HVS
should be unable to distinguish between the watermarked medical image and the original
medical image. Image fidelity is one of the major properties a watermarking system should
have, especially for medical image watermarking systems, where the slightest variation
may cause the wrong diagnosis. Therefore, medical image watermarking systems should
tend to keep the perceptivity as high as possible.
2.2 Image robustness
Robustness is the ability of the medical image watermarking system to withstand various
signal processing and geometric attacks [89]. Since these images are susceptible to attacks
including intentional as well as unintentional attacks, there is a requirement to check the
robustness of the watermark against these attacks. Even though all medical image water-
marking techniques need not be robust, some may be fragile. Fragile watermarks are those
that neither resists intentional nor intentional attacks.
2.3 Image payload
It is the amount of data bits that can be obscured within the medical image without affect-
ing/ degrading its quality. The payload can be embedded either to secure the image using
a watermark or to send the message along with the image while maintaining its perceptual
quality [9].
Fig. 1 Pre-requisites of medical image watermarking system
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2.4 Image security
The medical image watermarking algorithm is said to be secure if the intruder is not able
to extract the information embedded within the image [1]. Security of medical image is of
prime importance due to the presence of crucial data including patient information, insur-
ance information, and health-related information. This is usually obtained by the use of
encryption keys with large key space while embedding and extracting the medical image
watermark.
2.5 Watermark invisibility
Imperceptivity or watermark invisibility is the measure of similarity between the cover

medical image (CMI) and the Watermarked Medical Image (WMI). It is the measure for
the level of invisibility of the watermark in WMI and can be calculated as Peak Signal to
Noise Ratio (PSNR) and Structural Similarity Index Metric (SSIM) [50, 88].
2.6 Reversibility
The reversibility is of paramount importance in the case of medical images since the slight-
est variation in medical image data may cause misdiagnosis leading to life-threatening con-
sequences. Even after embedding the watermark or hiding data within the image, we can
reconstruct the original image if the method is reversible. Although the watermarked image
is not distortionless, the recovered image is distortion-free [26, 69].
2.7 Computational complexity
The complexity of the algorithm is determined by the time taken for its execution i.e.,
the time required for embedding and extraction of medical images. Medical image water-
marking algorithms being mostly real-time, need to be efficient and computationally less
complex [25].
2.8 Reliability
The MIWT needs to maintain the integrity, confidentiality, and authenticity of the data.
This factor helps in gaining the trustworthiness of the patients over the electronic health-
care setup. Integrity ensures that the medical image data has not been manipulated or mod-
ified. Confidentiality ensures that only the authorized person has the access to the medical
image data while authenticity ensures that the received medical image data is correct and
authentic [57].
Further, we present the evaluation parameters and applications of various prerequisites
in tabular form (Table 3).
3 The general framework for digital image watermarking system
Digital watermarking is the method for hiding data in digital media. The watermark is hid-
den imperceptibly such that it can be used later for the identification and validation of data.
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Table 3 Evaluation parameters and their applications for MIWT
Pre-requisite Evaluation parameter Applications
Image Fidelity PSNR Copyright protection of medical images.

Image Robustness Normalized Correlation Coefficient (NCC), BER, Accu- Copyright protection, authentication, and verification of integrity
racy Ratio (AR) in medical images.

Image Payload Bits per pixel (bpp) Verification of integrity and detection of tamper in medical images.
Watermark Invisibility PSNR, SSIM, MSE Image integrity protection.
Reversibility Image Reversibility Metric (IRM) Lossless recovery of medical image.
Computational complexity Execution Time (ET) Applicability in real-time processing.
1413
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3.1 Basic elements of watermarking approaches
There are three basic components included in various watermarking approaches and these include:
a) Generation of watermark
The watermark generation may vary for different applications according to speci-
fied properties and preferred objectives. Figure 2 depicts the process of generation of
watermarking.
b) Hiding of watermark
Once the watermark is generated, it is hidden within the image to generate the water-
marked image using a data hiding key. Figure 3 depicts the process of hiding the watermark.
c) Extraction of watermark
At the receiver end, the process of extraction is done by performing a reverse informa-
tion-hiding algorithm along with the use of the key. Figure 4 depicts the process of extrac-
tion of the watermark.
3.2 Basic components of medical image watermarking system
Section 3.1 described the general components of watermarking system. In this section, we
introduce various other components required for MIWT. Figure 5 shows the components of
medical image watermarking systems. These include:
a) Generation of the medical image
Various methods including Computed Tomography Scan (CT), X-Rays, Magnetic

Resonance Imaging (MRI), and other modalities have been developed in order to deliver
better healthcare services to patients. It has helped doctors in proper diagnosis and hence
is most commonly used. Medical images are collected according to the requirements of
the patient. Once these images are generated, they can be used for diagnosis [12].
Fig. 2 Generation of the watermark
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Fig. 3 Process of hiding the watermark
Fig. 4 Process of extraction of the watermark
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Fig. 5 Basic components of medical image watermarking system
b) Storage of medical image
After the generation of medical images, there is a need to store these medical images [64].
c) Data embedding and generation of authentication information
The EHI simultaneously with the authentication data is embedded within the medi-
cal image. After embedding this data in the medical image, we obtain a watermarked
medical image that can be used for authentication prior to diagnosis [25].
d) Communication networks
The watermarked medical image is sent over an insecure communication network for
remote doctor’s advice or a second opinion.
e) Receipt of medical image
The medical image sent over communication networks is received via different devices
including personal computers, smartphones, etc.
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f) Data extraction and verification of authenticity
On reception of the medical image, the data including patient information and authen-
tication bits need to be extracted to verify the authenticity of the medical image. This is an
important part of MIWT since unverified images may lead to wrong diagnosis and loss of
patient information [25].
g) Sharing for diagnosis
On verification of the medical image, it is shared with the doctor for diagnosis and
required treatment.
4 Applications of MIWT’s
For safeguarding and securing medical images against various malicious attacks, water-
marking plays an important role. The various applications of MIWT’s include:
a) Providence of EHR
The EHR’s are embedded within the medical images for protecting their confidential-
ity. In region-based methods, this confidential information is embedded in Non-Region of
Interest (NROI) in order to save the Region of Interest (ROI) from any degradation.
b) Providence of medical prescription
Medical professionals these days tend to store and share medical prescriptions. These
electronic prescriptions can be shared with other remote doctors for their opinion. It has
made electronic healthcare cost-effective and easily accessible.
c) Providence of sensitive data
MIWT’s tend to secure patient information like insurance information, patient identity,
patient payment information, etc. this information needs to be protected and secured since
privacy, confidentiality, and trustworthiness are main necessities for MIWT’s.
d) Providence of medical image
An enormous amount of medical image data is generated in healthcare centers due to
the gaining speed of electronic healthcare setups. This data is sent over the insecure chan-
nels for remote diagnosis and further monitoring of the patient. Various image modalities
include CT scans, MRIs, ultrasonography, echocardiography, radiography, and functional
MRI. The MIWT’s should be designed in a way that should conceal the information with
nominal distortion.
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5 Watermarking techniques for medical images
Watermarking is considered to be the best solution for protecting EPR’s containing sen-
sitive patient information while the transmission of medical images [4, 16, 18, 21, 36,
38]. The fact that transmission over insecure channels leads to the stealing of biomedical
images, has become a substantial concern for various researchers. This data is usually at
risk of being manipulated intentionally or unintentionally. Further, the data can undergo
various malicious attacks that may cause a loss of trustworthiness in the newly developed
medical image communication system. Watermarking has been considered to be the best
solution for the authentication and protection of medical images and EPR’s containing sen-
sitive patient information while transmitting insecure channels.
Medical image authentication can be performed using the following two methods
(Fig. 6).
5.1 Image‑based watermark embedding
A logo or a watermark containing patient information is used for the validation of medi-
cal images [25]. This image can be encrypted prior to data embedding so that it cannot be
decrypted other than a person who has the decryption keys.
The process of image-based watermarking is shown in Fig. 7.
5.2 Self‑generated watermark embedding
For authentication of medical images, a watermark required to authenticate the medical

image data is generated from the image itself [70, 82]. This makes the watermarking algo-
rithm dynamic in nature since the watermark is different for different images. The water-
mark can also be encrypted and embedded using a security key to obtain the watermarked
image. The process of self-generated watermark embedding is shown in Fig. 8.
The watermarking techniques for image authentication can be either block-based [11,
25] or pixel-based [94, 97]. Pixel-based algorithms show higher accuracy because of the
fact that in the block-based method, the presence of even a single altered pixel in the block
leads to the declaration of the whole block as invalid. The authentication watermark can be
further utilized for tamper detection, localization, and recovery (Fig. 9).
Over years, various medical image authentication techniques have been presented [6,
10, 66, 76, 96] with different motives including tamper detection, tamper localization, and
tamper recovery [22, 75]. The techniques developed for watermarking medical images
Fig. 6 Methods of medical image authentication techniques
13
Fig. 7 Process of image-based watermarking
should take image quality as a priority because distortion in these images can be fatal.
These techniques should be computationally efficient as they have real-time applications.
Watermarking techniques for Medical Image Authentication (WTMIA) are either region-
based [46] or whole image based [25]. In the region-based method, there is the division of
the medical image into ROI and NROI [69]. ROI contains the major portion of concern for
diagnosis and hence needs to be accurate. For such a purpose, many watermarking tech-
niques do not consider ROI for watermarking or data hiding. Also, many reversible data-
hiding techniques have been developed for embedding watermark in ROI. The reversible
Fig. 8 Process of self-generated watermark embedding
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Fig. 9 Utilization of Medical image authentication watermarking
watermarking techniques have the ability to reconstruct the lossless image at the receiver
making it an efficient method for medical image watermarking.
For various WTMIA, there is always a trade-off. On increasing the data (i.e., detecting,
localizing, and recovering the tamper), there will be a decrease in perceptual quality. In
such a case, region-based watermarking plays a significant role wherein tamper detection,
localization, and recovery of ROI is a priority. This decreases the number of bits being
embedded within the image there are some cases the whole image is important for diagno-
sis by a remote doctor.
6 Classification of MIWT’s based on domains
The MIWT’s can be classified into two groups based on domain. These are discussed in the
following subsections.
6.1 Spatial domain techniques
The spatial domain techniques for MIW modify the pixel intensity values of the medical
image directly [57]. These techniques are computationally efficient, simple, and provide a
higher payload. Spatial domain techniques provide the above-mentioned advantages but at
the same time have several disadvantages. These techniques do not survive certain attacks.
Also, the discovery of the watermarking techniques used for embedding can easily give
access to the unauthorized user to obtain and alter the embedded watermark. Figure 10 a
shows the general flow diagram for spatial domain watermark embedding and Fig. 10 b
shows watermark extraction.
a) Least Significant Bit Substitution (LSB)
It is one the oldest and yet simple methods for watermarking in the spatial domain. It is
done by embedding the watermark in LSB [74]. The watermark is encoded before embed-
ding. To embed the encoded bits, the pixel values are converted to the binary form and the
rightmost bit of every pixel is replaced by the encoded watermark bits. After the replace-
ment of LSB, the binary value image pixel is converted back to the decimal value image
pixel. This has been illustrated in Fig. 11 a. Further, the flow graph for LSB substitution
has been shown in Fig. 11 b.
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Fig. 10 a The general flow diagram for spatial domain watermark embedding. b The general flow diagram
for spatial domain watermark extraction
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b) Modification of image histogram
Histogram modification is another spatial domain technique that has been used for data
hiding in the medical image [69]. This scheme makes use of peak bins to embed data in a
histogram. This method is easy to implement, yet its embedding capacity is restricted to a
number of maximum or peak points that are available.
c) Local Binary Patterns
LBT is the spatial domain technique that makes use of the difference value between the
central pixel and other pixels. It segments the image into non-overlapping blocks before
calculating the differences. Then, embedding is done in these pixels according to the rules
given in [91].
6.2 Transform domain techniques
Transform domain techniques generate the transform coefficients once they are applied
to medical images. These coefficients are used for embedding the data. The most com-
monly used transform domain techniques include Discrete Fourier Transform (DFT),
Discrete Cosine Transform (DCT), and Discrete Wavelet Transform (DFW). The gen-
eral flow graph for data embedding and extraction in the transform domain is presented
in Fig. 12 a and 12 b respectively. At first, the image is transformed using a specific
transformation. Then embedding is carried in the coefficients of the transform domain.
The embedded data can be the authentication data or a logo required for verification of
the medical image. After embedding the data, the image is transformed back to its origi-
nal form for obtaining the watermarked image. At the receiver, extraction of the embed-
ded data along with the generation of authentication data is carried out to validate the
image. If the generated data is similar to that of embedded data, then the algorithm is
terminated and the image is considered to be valid else tamper detection, localization,
and recovery are carried out to obtain the tamper-corrected image.
These transform domain techniques have been discussed as under:
a) Discrete Fourier Transform
It is the most approachable technique for the conversion of medical image from the
spatial domain to the transform domain [76]. It decomposes the Medical image into sine
and cosine forms. It has the ability to provide resistance against various geometrical
attacks. Let f t(k, l) represent the image with dimensions P×Q, k = 0, 1, 2, …, (P-1) and l
= 0, 1, 2, …, (Q-1). The DFT and Inverse DFT (IDFT) can be calculated using the fol-
lowing formulas
P−1 Q−1 ( )
mk nl
∑ ∑ −j2𝜋 −Q
FT (m, n) = ft (k, l)e P
(1)
k=0 l=0
And
P−1 Q−1 ( )
1 ∑∑ j2𝜋 mk + nl
fT (k, l) = FT (m, n)e P Q
(2)
PQ m=0 n=0
13
(a)
(b)
Fig. 11 a LSB substitution in image pixels. b Flow graph for LSB substitution
13
Fig. 12 a The general flow diagram for transform domain watermark embedding. b The general flow dia-
gram for transform domain watermark extraction and authentication
13
Here FT(u, v) is DFT coefficient with u = 0, 1, 2, …, P-1 and v = 0, 1, 2, …, Q-1.

DFT composes the image into amplitude part and Phase part. The amplitude part is
used for watermark embedding since it contains a lesser amount of information in it and
helps in the reduction of image distortion.
b) Discrete Cosine Transform
DCT provides an attractive and efficient image transformation that maps linearly and
the n-dimensional vector to n number of coefficients. It divides the image into three
different frequency components: Low-Frequency Component (LFC), Middle-Frequency
Component (MFC), and High-Frequency Component (HFC). The highest amount of
energy is compressed LFC [73]. DCT has higher robustness towards JPEG compression
but shows a lag in resistance toward the geometric attacks including cropping, rotation,
scaling, etc. the DCT and its inverse have been shown in the following equations.
p−1 q−1 � � � �
2 � � (2x + 1)u𝜋 (2y + 1)v𝜋
CT (u, v) = √ 𝛽(u)𝛽(v) fT (x, y) × Cos × Cos
pq x=0 y=0
2p 2q
(3)
And
p−1 q−1 � � � �
2 �� (2x + 1)u𝜋 (2y + 1)v𝜋
ft (x, y) = √ 𝛽(u)𝛽(v)fT (x, y) × Cos × Cos (4)
pq u=0 v=0 2p 2q
Here p and q are the block size and fT(x, y) represents the original image pixel,
CT(u, v) is the transform domain coefficient and β(u) and β(v) is calculated as
� 1
√ , if u, v = 0
𝛽(u), 𝛽(v) = 2 (5)
1, else
c) Discrete Wavelet Transform

DWT is the most efficient and commonly used transform domain technique. Due to
the multi-resolution properties, it provides accurate spatial localization. It decomposes the
image into four sub-bands including Low Low (LL), Low High (LH), High Low (HL),
and High High (HH) as shown in Fig. 13. LL sub-band contains the most significant infor-
mation regarding the image details while other sub-bands contain the detail that is missed
in LL sub-band. Further, DWT offers the decomposition of LL sub-band hierarchically
[13, 86]. The energy in the case of DWT is calculated using the following equations.
1 ∑∑
EN =
PN QN k l
∣ IC (k, l) ∣ (6)
Here N represents the number of levels considered for decomposition, PN and QN repre-
sent image dimensions and IC gives the coefficients of the current sub-bands.
Further, we present the pros and cons of the spatial domain and transform domain tech-
niques for the readers to get better discernment for choosing the domain of watermarking
according to their requirements (Table 4).
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Fig. 13 Decomposition of the sub-bands in DWT
7 State of the Art watermarking techniques for medical image
7.1 Classical watermarking techniques for medical images
Classical watermarking or conventional watermarking takes whole image into consid-

eration for watermarking. In medical images, distortion is not feasible and no radiologist
may accept a distorted image for diagnosis. It may lead to wrong diagnosis leading to an
increase in research pertaining to reversible data hiding (RDH). RDH has the capability to
restore the original image from the image in which data is hidden. Figure 14 a shows the
classical approach for embedding data while Fig. 14 b shows the extraction process.
Table 4 Pros and Cons of Spatial domain and Transform domain techniques
Domain Pros Cons
Spatial Domain • Easy to implement. • Being easy to implement makes it easier

• Computationally efficient. for hackers to crack the algorithm.
• Provides better visual quality with a • Usually fragile, therefore cannot with-
higher payload. stand any of the attacks.
• Offers reversibility. • Most of the algorithms are based on
• Causes least variation in image pixel LSB Substitution.
values.
Transform Domain • Provides robustness against various • Difficult to implement.
attacks. • Computationally complex.
• Provides higher security due to • Does not prove better visual quality
embedding of watermark in coef- when compared to spatial domain.
ficients of the frequency domain. • Reversibility is difficult to achieve.
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(a)
(b)
Fig. 14 a Classical approach for data embedding in medical images. b Classical approach for data extrac-
tion in medical images
The state-of-the-art techniques along with evaluation parameters, pros, and cons of clas-
sical watermarking techniques for medical image watermarking have been presented in
Table 5 [14, 25, 27, 33, 47, 48, 56, 66, 71, 86].
7.2 Reversible watermarking for medical images
Embedding data into an image may lead to distortion of the image when compared to
the original image. This distortion may lead to the wrong diagnosis and may prove
fatal for the patient’s health. For such a purpose, reversible data-hiding techniques
have been developed. These techniques can reconstruct the original image along with
the embedded data accurately. Figure 15 a shows the framework for data embedding
in reversible watermarking techniques for medical images and Fig. 15 b shows the
data extraction and reconstruction of the original image after the extraction of hid-
den data.
The state-of-the-art techniques along with evaluation parameters, pros, and cons of
reversible watermarking techniques for medical image watermarking have been presented
in Table 6 [24, 26, 29, 32, 34, 40, 43, 52, 53, 67, 92].
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Table 5 Evaluation Parameters, Pros, and Cons of classical watermarking techniques for medical image watermarking
1428
Scheme Watermark Technique used Evaluation parameters Pros Cons Robustness
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Moniruzzaman et al. PI DWT PSNR, NC, BER • Uses chaotic map for secur- • Shows no robustness Robust
(2014) ing PI. against attacks like
rotation.
Parah et al. [56] EPR, Logo DCT PSNR, SSIM, NAE, • Authentication, integrity, • The method does not Robust
BER, NCC and copyright protection is show robustness to
achieved. rotation attacks.
Singh et al. [71] Logo DCT, DWT, SVD PSNR, BER, NC • Achieves better robustness • Computational com- Robust
due to the use of combined plexity is high due to
transform schemes. use of transforms.
Gull et al. [25] Logo LSB Substitution PSNR, SSIM, Capacity • Detects and localizes tamper • Watermark security Fragile
at 4×4 block level. has not been consid-
ered.
Sabbane and Tairi (2019) PI, Logo Polynomial Decom- PSNR, MSE, NC, • The algorithm has the abil- • The scheme can be Robust
position Capacity ity to select the regions for enhanced in terms of
embedding. visual quality along
with capacity.
Hermandez et al. (2020) PI Spread Spectrum PSNR, SSIM • It enables validation and • The technique is only Robust
Technique, zero verification of PI. robust to lossy and
watermarking lossless compression.
Gull et al. [1] Self-generated DNA encoding, LSB PSNR, SSIM, FPR, • Encrypts the watermark and • The technique has Fragile
watermark Substitution. FNR, Capacity then embeds into the LSB’s. not been checked for
• It detects and localizes recovery of tampers in
tamper. the images.
Jana et al. [33] Self-generated AMBTC and Fuzzy PSNR, MSE, SSIM, • Categorizes the blocks as • Not resilient to vetor Robust
watermark logic TDR, TRR,TR smooth and complex. quantization and com-
• It detects, localizes, and pression.
recovers the tamper.
Moad et al. [47] Fingerprint and DWT, HASH PSNR, SSIM, bpp, • Uses AMBTC for compres- • Less capacity Robust
patient photog- NCC, BER sion. • Computational com-
raphy • RC4 is used for security. plexity is high
(a)
(b)
Fig. 15 a Embedding stage for reversible data hiding. b Extraction and reconstruction stage of reversible
data hiding
7.3 Region‑based watermarking techniques for medical images
Medical images can be divided into two regions namely ROI and NROI. ROI contains
the important region for diagnosis purpose while the region other than ROI mostly con-
tains black background which has no significance for diagnosis [69]. Usually, ROI is not
preferred for data hiding since it contains significant information and its distortion is not
acceptable. There are several methods that use NROI for hiding data but these methods
have certain shortcomings. In this method, the amount of data to be embedded is deter-
mined by the size of the NROI. Further, it does not protect ROI from various malicious
attacks. Also, these methods can only be implemented if NROI is present. Figure 16 a and
16 b show the data embedding and extraction in the case of region-based methods.
The state-of-the-art techniques along with evaluation parameters, pros, and cons of the
region-based watermarking techniques for medical image watermarking have been pre-
sented in Table 7 [2, 17, 35, 42, 45, 55, 62, 74, 77, 80].
13
Table 6 Evaluation Parameters, Pros, and Cons of Reversible data hiding techniques for medical image watermarking
1430
13
Huang et al. [29] Secret data bits Histogram Shifting PSNR, Capacity • Difference bit embed- • Overflow and under- Robust
ding has been used. flow problem exists.
• Tested on DICOM • Low embedding
images. Capacity.
Lei et al. [40] Secret data includ- Wavelet Transform, PSNR, Capacity, • The algorithm inserts • Embedding rates are Robust
ing Logo, Tag, and SVD, Recursive Dither MSSIM, NCA dual watermarks into low.
Signature. Modulation, and Differ- the image. • The algorithm is
ential Evolution complex.
Wu et al. [92] Secret data bits Background Segmenta- PSNR, SSIM, Capacity, • The contrast of ROI • Embedding rates are -
tion, Contrast Enhance- Computational time has been enhanced. low.
ment using Histogram
Modification.
Jafar et al. [32] Secret data bits Prediction error PSNR, Computational • Uses simple predictors. • Embedding capacity -
time • Dual image-based can be enhanced while
reversible data hiding maintaining PSNR.
method making one
image as a prediction
of another image.
Loan et al. [43] Secret data bits Pixel repetition method, PSNR, SSIM, Capacity, • Computational com- • It is a semi-reversible -
LSB substitution. Computational time plexity is very low. data-hiding scheme.
• RC4 algorithm has
been used for enhanc-
ing security.
Kaw et al. [34] Secret data bits Optimum pixel repetition PSNR, Capacity • OPR replaces the inter- • The authors state the Robust
(OPR) polation technique and complexity is low but
uses intermediate LSB it has not been shown
for data hiding. in the results.
Table 6 (continued)
Sahu and Swain [67] Secret data bits Pixel differences and PSNR, Capacity, SSIM • Obtains better PSNR • Evaluation of robust- Robust
modification LSB for higher embedding ness has been carried
Matching capacity. out only for S & P
noise, RS analysis, and
PDH analysis.
Govind and Judy (2020) Secret data bits Weighted interpolation, PSNR, Capacity, SSIM • Embedding is done in • Time-consuming. -
difference expansion, the original image pixel • Lower PSNR values.
modular arthematic as well increasing the
embedding capacity.
Gull et al. [26] Secret data bits Huffman encoding, PSNR, Capacity, SSIM • Data reduction is done • The usage of dual Fragile
advanced center folding using Huffman encod- images increases band-
ing. width requirements.
• Data is hidden in two
visually similar images
enhancing security.
Nunez Ramirez et al. Secret data bits Histogram modification Relative Entropy Error • Controls overflow and • Preprocessing is -
[53] (REE), SSIM, PSNR underflow. required before data
hiding.
Nasir et al. [52] Secret data bits Linear prediction, RC4 PSNR, SSIM, Capacity • Provides high per- • Embedding capacity Robust
encryption ceptual quality and can be enhanced while
capacity and resistance maintaining PSNR
to chi-square attacks.
1431
13
(a)
(b)
Fig. 16 a Embedding stage for region-based watermarking techniques. b Extraction stage for region-based
watermarking techniques
7.4 Authentication‑based watermarking techniques for medical images
Authentication of images is a part of watermarking schemes. The authentication water-

marking techniques for medical images (AWTMI) can perform operations including Medi-
cal Image Tamper Detection (MITD), Medical Image Tamper Localization (MITL), Medi-
cal Image Tamper Recovery (MITR), and EHR embedding (Fig. 17). MITD can be done
using a logo, generating the data using a hash function for ROI or whole image, the identity
of patients or doctors, medical image features, etc.
13
Table 7 Evaluation Parameters, Pros, and Cons of Region-based watermarking techniques for medical image watermarking
Das and Kunder [17] Electronic Patient Data Compression, Similarity Ratio (SR), • Localizes the image • The payload depends Fragile
Information Encryption, LSB Capacity, PSNR, blocks at 3×3 level. on the size of the
Substitution WPSNR, SSIM ROI.
Solanki and Malik Secret message bits DWT, RSA PSNR, MSE, Bit • Provides integrity • The technique does Robust
[77] Correct Rate (BCR), and authenticity of not provide a better
NCC medical image. result for rotation
attacks.
Aherrahrou and Tairi Binary bits and hospi- Partial Differential PSNR, NC • Evaluates the • The algorithm can Robust and Fragile
[2] tal logo Equation (PDE), authenticity and be enhanced by
DWT, DFT integrity of medical varying the image
images. segmentation tech-
nique.
Pandey et al. [55] Secure Hash Algo- DWT, SVD NC, BER, PSNR • Uses a cryptographic • Robust to only Robust
rithm (SHA) for hash function to two attacks viz.,

generation of the secure the water- compression and
watermark, Patient mark. checkmark.
Information (PI)
Khor et al. [35] Authentication and LSB Substitution PSNR, MSE, Compu- • It is computationally • Robustness towards Robust
recovery bits tational time efficient. other attacks can be
• Authenticates the enhanced.
ROI.
Swaraja [80] Logo of hospital and Firefly Optimized PSNR, Capacity, NC, • It utilizes multiple • The technique has Robust
PI Algorithm, DWT, BER watermarking. not been evaluated
Shur Transform for error correction
codes.
Liu et al. [42] PI Recursive Dither PSNR, BER, NC, • Provides reli- • The technique is not Robust
Modulation, Slantlet SSIM able authentication, robust against rota-
Transform, SVD tamper detection, tion attacks.
localization, and
recovery
1433
13
Table 7 (continued)
1434
13
Memon and Alzahrani Logo and PI Prediction-based PSNR, Capacity • Carries authentica- • The robust water- Both Robust and Fragile
[45] watermarking tion of ROI and mark implanted
technique, LSB helps in providing in NROI cannot
Substitution ownership via a withstand legitimate
watermark embed- attacks.
ded in RONI.
Ravichandran et al. Self-generated water- Integer Wavelet PSNR, MSE, SSIM • Detects, localizes, • NROI is robust, Robust
[62] mark Transform and recovers the ROI yet 100% accuracy
with 100% accuracy. on recovery is not
guaranteed.
Singh et al. [74] Self-generated water- Adaptive LSB substi- PSNR, SSIM, Mean • Robust to geometric • Optimization can be Robust
mark, Logo tution, DWT, SVD Opinion Score and non geometric enhanced using soft
(MOS), NC, BER attacks. computing
Fig. 17 Authentication-based watermarking techniques for medical images
MITL is usually done by generating the average of each block of the image, using a
logo, etc. MITR can be ROI-based or whole image based. It is usually done by consid-
ering the image pixels directly. Recovery of images increases image payload due to the
fact that recovery of the image requires more data. The data is either generated from
the average of each block or by using compression methods. EHR contains information
related to the patient including patient identity, medical prescription, insurance infor-
mation, payment information, etc. these watermarks are embedded either in the spatial
domain (pixel domain) or in the transform domain in a medical image [15, 25]. The
two main processes included in the watermarking process are watermark embedding
and extraction as discussed earlier. Depending on the applicability of watermarking,
the process of embedding and extraction is carried out. If we require only the detec-
tion of tamper in medical images, once detected the algorithm is terminated else the
algorithm goes on till it performs the function of localizing and recovering the tam-
per. Most of the MIAT applied in the spatial domain use LSB substitution, difference
expansion, exclusive OR, or chaotic key for watermarking. Spatial domain techniques
make use of DCT, DWT, and others. Further, the watermarking domain can be selected
on the basis of the required application.
Figure 18 a and 18 b show the framework for data embedding and extraction in
authentication-based watermarking schemes. The state-of-the-art techniques along
with evaluation parameters, pros, and cons of authentication-based watermarking tech-
niques for medical image watermarking have been presented in Table 8 [30, 41, 44, 51,
61, 63, 68, 79, 81, 85]. Further in Table 9 we present the comparative analysis of sev-
eral existing schemes in terms of PSNR, SSIM, and computational complexity.
8 Evaluation parameters for MIWT’s
For the evaluation of MIWT, various metrics can be calculated in order to determine the
degree of distortion of the watermarked image. Also, the extracted watermark can be tested
for its accuracy.
13
(a)
(b)
Fig. 18 a Embedding in authentication based watermarking schemes. b Extraction in authentication-based
watermarking schemes
13
Table 8 Evaluation Parameters, Pros, and Cons of Authentication-based watermarking techniques for medical image watermarking
Naseem et al. [51] Hash of the whole image RNS (Residual Number Subjective Fragility • Detects, localizes, and • PSNR and the capacity Fragile
System), CRT. Analysis. recovers tamper. of the algorithm have
not been evaluated.
Rayachoti et al. [63] Authentication data Run Length Encod- PSNR, WPSNR, • Detects, localizes, and • Low PSNR value of Fragile
and PI ing and Border Pixel MSSIM, Total Percep- recovers tamper. recovered image due to
Embedding. tual Error (TPE) • Uses dual watermarks. its reliability on aver-
age intensity.
Madhuri and Chaitanya Hash value of ROI SHA-1, LSB Substitu- PSNR, MSE • Detects and localizes • The scheme has not Fragile
[44] tion. and recovers tamper considered embedding
and embeds ROI data capacity.
into NROI.
Thabit and Khoo [85] Authentication data and Slantlet Transform Subjective evaluation. • Detects, localizes, and • The capacity of this Robust
ROI data (SLT), IWT recovers tamper. scheme is a concern if
• Uses multiple water- the ROI is large.

marks.
Ranjani and Babu [61] Hash Signatures RSA Encryption Sequen- Capacity, PSNR, • Provides higher capac- • It is not able to local- -
tial Square Encoding, MSSIM, SSIM cor- ity along with better ize and recover the
Diamond Encoding relation. visual quality. tamper.
Saju and Sreenimol [68] Hash Linear Interpolation, Subjective evaluation. • Tamper detection and • The method has -
DWT authentication. not been evaluated
in terms of PSNR,
capacity.
Swaraja et al. [81] EPR and ROI data DWT, Particle Swarn PSNR, NCC, Capacity, • Detects, localizes, and • It has a higher compu- Robust
Bacterial Foraging Subjective evaluation. recovers tamper and tational overhead.
Optimization Algo- is robust to a large
rithm (PSBFO) number of attacks.
Soualmi et al. [79] Binary watermark Quantization Index PSNR, NC, BER, • Computational • The method is not Robust
Modulation (QIM) Execution time. complexity is low and robust against rotation
offers high-end secu- attacks.
rity to watermark.
1437
13
Table 8 (continued)
1438
13
Hussan et al. [30] Self embedding LSB substitution PSNR, SSIM, computa- • Detects, localizes, and • The quality of recov- Fragile
tional time, TR recovers tamper ered images is poor.
Lin et al. [41] AMBTC, VQ Com- PSNR,TR, FPR,FNR • Detects, localizes, and • Time comparison has Fragile
pression recovers tamper. not been provided.
• Better quality of recov- • Quality of recovered
ered images. images can be further
improved.
Table 9 Evaluation Parameters Method Average PSNR Average SSIM Compu-

for various techniques presented tational
in the review Time
Hussan et al. [30] 44.15 0.9948 2.2538

Jana et al. [33] 48.28 0.95 -
Gull et al. [27] 51.94 0.9962 -
Nasir et al. [52] 50.04 0.9950 -
Gull et al. [26] 49.16 0.9988 0.07
Singh et al. [74] 45.93 0.9234 0.026
Ravichandran et al. [62] 48.85 0.9928 -
Lin et al. [41] 48.21 - -
8.1 Assessment of watermarked medical Images
Various parameters including Peak Signal to Noise Ratio (PSNR), Mean Square Error
(MSE), and Structural Similarity Index Matrices (SSIM) can be calculated for the estima-
tion of distortion among the original and watermarked image. For an image (O) of size
P×Q and watermarked image OW, the above-mentioned parameters are calculated as under:
a) Mean Square Error
MSE can be calculated among O and OW using the following equation [50].
P−1 Q−1
1 ∑∑( )2
(7)
( )
MSE O, OW = O(k, l) − OW (k, l)
PQ k=0 l=0
b) Structural Similarity Index Metrics
SSIM gives the measure of correspondence among the images O and OW. It can be
calculated using an equation [90].
)]𝛼 [ ( )]𝛽 [ ( )]Υ
(8)
( ) [(
SSIM O, OW = l O, OW . c O, OW . s O, OW
Here,
( ) 2μO μOW + E1
l O, OW = (9)
μO 2 + μOW 2 + E1
( ) 2𝜎O 𝜎OW + E2
l O, OW = (10)
𝜎O 2 + 𝜎OW 2 + E2
𝜎OOW + E3
(11)
( )
l O, OW =
𝜎O 𝜎OW + E3
13
In the above equations, μO, μOW are local means, σ0, σ0W are standard deviations and
σOOW is the cross-covariance between the two images O and OW. On default selection of
exponents and E3, the equation is reframed as under
( )( )
2μO μOW + E1 2𝜎OOW + E2
(12)
( )
SSIM O, OW = ( )( )
μO 2 + μOW 2 + E1 𝜎O 2 + 𝜎OW 2 + E2
c) Peak Signal to Noise Ratio

PSNR is the measure of visual quality distortion among the two images O and OW. A high
value of PSNR depicts higher visual similarity between the images [6]. PSNR is calculated
using the following equation.
2552
(13)
( )
PSNR O, OW = 10 log10
MSE
PSNR is determined in terms of decibels (dB)
A high PSNR value indicates better perceptual quality. A PSNR value of 100 dB indicates
no distortion. PSNR value of above 40 dB is acceptable for medical images. SSIM close to 1
indicates better image similarity. BER value close to 0 indicates lesser distortion among the
original and watermarked image.
8.2 Assessment of extracted watermarked
To verify the reliability of the extracted watermark, various parameters can be evaluated.
Let ‘L’ be the embedded logo or watermark and L’ be the extracted watermark, following
are the various metrics calculated for assessment of extracted watermark.
a) Correlation coefficient (CR)
CR is used to analyze the correspondence between L and L’. Its value ranges from 0 to 1
and it is calculated using the following equation [31].
∑ ∑ �
k l L(r, s)L (r, s)
CR = �
∑ ∑ 2 ∑ ∑ � 2
(14)
k l L(r, s) × k l L (r, s)
b) Bit Error Rate (BER)
BER is the metric that gives the measure of wrongly extracted bits in binary sequence [28].
Lower BER depicts the efficiency of the embedding algorithm. BER is calculated as
Number of wrongly decoded bits
BER = (15)
Total number of watermark bits
13
c) Accuracy Rate (AR)

AR is metric that gives the measure of correctly extracted bits in a binary sequence [28].
The higher the value of AR, the better is the embedding algorithm. It can be calculated using
the following equation.
Number of correctly decoded bits
AR = (16)
Total number of watermark bits
8.3 Assessment of embedding capacity
Embedding capacity or payload refers to the total number of binary data that can be
embedded in the medical image using a particular watermarking algorithm. The payload
can be calculated using the following equation.
Number of binary bits that can be embedded
EC = (17)
Number of pixels in medical image
8.4 Assessment of False Positive and False Negative Rates
In authentication-based watermarking schemes, classification on the basis of erroneous

detection of pixels as tampered or non-tampered is done. False Positive Rates give the
number of pixels erroneously detected as non-tampered whereas False Negative Rates
(FNR) give the number of pixels erroneously detected as tampered. Further, the Tamper
Detection Rate (TDR) gives the proportion of pixels sensed as tampered to the overall
tampered pixels.
False detected tampered pixels
FPR % = × 100 (18)
Total number of pixels present in tampered regions
False detected non tampered pixels

FNR % = × 100 (19)
Total number of pixels present in non tampered regions
Number of pixels detected as tampered

FDR % = × 100 (20)
Number of actual tampered pixels
9 Potential issues and challenges
Plenty of research has been carried out for watermarking in medical images. Various
methods have been developed for the purpose of medical image authentication. Yet,
there are potential issues and challenges that limit the practicality of health-related
watermarking systems. This can be attributed to the fact that a trade-off always exists
amid the necessities of watermarking systems (i.e., perceptivity, payload, security,
robustness). It is not possible to accomplish these requirements altogether. For such a
13
purpose, the medical image watermarking system should be able to attain a better trade-
off among the above-given requirements. The potential issues and challenges of medical
image watermarking techniques observed from the above-mentioned schemes have been
summarized below
• Medical image watermarking systems should attain better trade-offs among perceptiv-
ity, payload, and robustness.
• These techniques have real-time applications, therefore should be computationally efficient.
• Reversible data hiding is found to be an efficient technique in medical images, due to its
ability to reconstruct the original cover at the receiver.
• Compression techniques can be used for the enhancement of image payload while
reducing storage requirements.
• Several methods in medical image watermarking are able to detect tampered regions,
but only a few are able to reconstruct these regions.
• The time requirements for embedding/encryption, extracting/ decryption, and image recon-
struction need to be considered because the process altogether should not be time-consuming.
• For enhancing the security of medical images and EHI encryption algorithms can be
used. However, there is a need to consider other parameters that depict the efficiency of
the system.
• On developing the medical image watermarking system, it should be evaluated for its
performance on various image processing and geometric attacks.
• In ROI and NROI-based watermarking techniques, there is a possibility of the absence
of NROI. Even if the NROI is present its size depicts the amount of data that can be
hidden in the image.
• To ensure reliability and perceptual quality, almost every method makes use of two
benchmarks namely PSNR and SSIM. Yet, there is a need for considering clinically
relevant information in order to provide an accurate diagnosis. Therefore, the addition
of benchmarks that access the watermarking system clinically to enhance its relevance
and credibility should be considered.
10 Conclusions
Medical image watermarking is taking a lead in the present world and has the latency to pro-
vide an appreciable solution for various applications of e-healthcare. The challenges do not only
include confidentiality but also include the prevention of manipulations because of authorized
or unauthorized users, so that trust may be built in the e-healthcare setups. Several medical
image watermarking techniques have been developed in spatial and transform domains with
a different applicability. This paper presents a compendious survey of various medical image
watermarking techniques using classical methods, reversible data hiding, ROI-based water-
marking, and authentication-based watermarking. Further, various prerequisites along with the
general framework of medical image watermarking and its capabilities have been discussed.
We have presented the critical review in tabular form for various notable medical image water-
marking schemes. The aim of this survey is to help future researchers to propose medical image
watermarking techniques that might address the potential issues and challenges in e-healthcare
setups. Furthermore, these techniques can be collaborated with machine learning algorithms [5,
65, 78] for providing better security.
13
Appendix
List of Abbreviations
Abbreviation Meaning
IoT Internet of Things
IoMT Internet of Medical Things
MIAT Medical Image Authentication Technique
MIP Medical Image Processing
MITD Medical Image Tamper Detection
MITL Medical Image Tamper Localization
MITR Medical Image Tamper Recovery
MIW Medical Image Watermarking
MIWT Medical Image Watermarking Technique
WMI Watermarked Medical Image
WTMIA Watermarking Techniques For Medical Image Authentication
EHI Electronic Health Information
EPI Electronic Patient Information
CT Computed Tomography
MRI Magnetic Resonance Imaging
ROI Region of Interest
RONI Region of Non Interest
LSB Least Significant Bit
DCT Discrete Cosine Transform
DWT Discrete Wavelet Transform
DFT Discrete Fourier transform
LFC Low Frequency Component
MFC Middle Frequency Component
HFC High Frequency Component
HH High High
LL Low Low
HL High Low
LH Low High
RDH Reversible Data Hiding
Data availability Data can not be made available due to Intuition policy.
Declarations
The authors have no relevant financial or non-financial interests to disclose.
The authors have no competing interests to declare that are relevant to the content of this article.
All authors certify that they have no affiliations with or involvement in any organization or entity with any
financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.
The authors have no financial or proprietary interests in any material discussed in this article.
13
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Multimedia Tools and Applications (2024) 83:1407–1447

Advances in medical image watermarking: a state of the art

Solihah Gull1 · Shabir A. Parah1

Received: 7 January 2022 / Revised: 21 February 2023 / Accepted: 18 April 2023 /

Keywords Electronic Patient Record · Watermarking · Medical Images · Authentication ·

• Since the data is in intangible form, the intruders

Nyeem et al. [54] 2013 Applications and requirements of teleradiography

2 Prerequisites for Medical Image Watermarking Techniques

Fig. 1 Pre-requisites of medical image watermarking system

Imperceptivity or watermark invisibility is the measure of similarity between the cover

3 The general framework for digital image watermarking system

Image Fidelity PSNR Copyright protection of medical images.

racy Ratio (AR) in medical images.

3.1 Basic elements of watermarking approaches

3.2 Basic components of medical image watermarking system

a) Generation of the medical image

Various methods including Computed Tomography Scan (CT), X-Rays, Magnetic

Fig. 2 Generation of the watermark

Fig. 3 Process of hiding the watermark

Fig. 4 Process of extraction of the watermark

Fig. 5 Basic components of medical image watermarking system

b) Storage of medical image

e) Receipt of medical image

f) Data extraction and verification of authenticity

g) Sharing for diagnosis

b) Providence of medical prescription

5 Watermarking techniques for medical images

5.1 Image‑based watermark embedding

5.2 Self‑generated watermark embedding

For authentication of medical images, a watermark required to authenticate the medical

Fig. 6 Methods of medical image authentication techniques

Fig. 7 Process of image-based watermarking

Fig. 8 Process of self-generated watermark embedding

Fig. 9 Utilization of Medical image authentication watermarking

6 Classification of MIWT’s based on domains

6.1 Spatial domain techniques

a) Least Significant Bit Substitution (LSB)

b) Modification of image histogram

6.2 Transform domain techniques

a) Discrete Fourier Transform

Here FT(u, v) is DFT coefficient with u = 0, 1, 2, …, P-1 and v = 0, 1, 2, …, Q-1.

b) Discrete Cosine Transform

c) Discrete Wavelet Transform

Fig. 13 Decomposition of the sub-bands in DWT

7 State of the Art watermarking techniques for medical image

7.1 Classical watermarking techniques for medical images

Classical watermarking or conventional watermarking takes whole image into consid-

Spatial Domain • Easy to implement. • Being easy to implement makes it easier

7.2 Reversible watermarking for medical images

Scheme Watermark Technique used Evaluation parameters Pros Cons Robustness

7.3 Region‑based watermarking techniques for medical images

Scheme Watermark Technique used Evaluation parameters Pros Cons Robustness

7.4 Authentication‑based watermarking techniques for medical images

Authentication of images is a part of watermarking schemes. The authentication water-

rithm (SHA) for hash function to two attacks viz.,

Scheme Watermark Technique used Evaluation parameters Pros Cons Robustness

Fig. 17 Authentication-based watermarking techniques for medical images

8 Evaluation parameters for MIWT’s

• Uses multiple water- the ROI is large.

Scheme Watermark Technique used Evaluation parameters Pros Cons Robustness

Table 9 Evaluation Parameters Method Average PSNR Average SSIM Compu-

Hussan et al. [30] 44.15 0.9948 2.2538

2 Prerequisites for Medical Image Watermarking Techniques

3 The general framework for digital image watermarking system

3.1 Basic elements of watermarking approaches

3.2 Basic components of medical image watermarking system

5 Watermarking techniques for medical images

5.1 Image‑based watermark embedding

5.2 Self‑generated watermark embedding

6 Classification of MIWT’s based on domains

6.1 Spatial domain techniques

6.2 Transform domain techniques

7 State of the Art watermarking techniques for medical image

7.1 Classical watermarking techniques for medical images

7.2 Reversible watermarking for medical images

7.3 Region‑based watermarking techniques for medical images

7.4 Authentication‑based watermarking techniques for medical images

8 Evaluation parameters for MIWT’s

8.1 Assessment of watermarked medical Images

8.2 Assessment of extracted watermarked

8.3 Assessment of embedding capacity

8.4 Assessment of False Positive and False Negative Rates

9 Potential issues and challenges