Skip to main content
SpringerLink
Log in

Security Analysis of the Internet of Medical Things (IoMT): Case Study of the Pacemaker Ecosystem

  • Conference paper
  • First Online:
Biomedical Engineering Systems and Technologies (BIOSTEC 2022)

Part of the book series: Communications in Computer and Information Science ((CCIS,volume 1814))

  • 169 Accesses

Abstract

During the pandemic, the Internet of Medical Things (IoMT) has played a key role in reducing unnecessary hospital visits and the burden on health care systems by providing home-based hospital services and ambulatory nursing services. As IoMT devices handle patient data and are connected over the Internet to the complex hospital Information and Communication Technology (ICT) infrastructure, their role in the transformation of healthcare services will introduce a range of new potential risks. Over the past years, several demonstrated attacks in the healthcare domain have indicated cyber security challenges for integrating IoMT devices.

In this paper, we experimentally evaluate the potential risks that accompany the integration of a given IoMT device, here a connected pacemaker, from a hardware and network security perspective. We take a black box testing approach to the pacemaker ecosystem and find key shortcomings that enable several practical and low-cost attacks that impact a patient’s safety and privacy. In particular, we demonstrate the ability to gain control over the home monitoring device and to perform man-in-the-middle attacks. We find that it is possible to bypass hardware security protection mechanisms, to perform remote denial of service attacks, and other attacks. Lastly, we discuss the potential trade-offs in security protection choices and mitigation techniques.

This work was funded by Reinforcing the Health Data Infrastructure in Mobility and Assurance through Data Democratization, a five-year project (grant number 28885) under the Norwegian IKTPLUSS-IKT and Digital Innovation programme.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Notes

  1. 1.

    See https://greatscottgadgets.com/hackrf/.

References

  1. OWASP firmware security testing methodology. https://scriptingxss.gitbook.io/firmware-security-testing-methodology/

  2. Block, C.C.: Muddy waters report - St. Jude Medical, Inc. Technical report, Muddy Waters Capital LLC (2016). http://www.muddywatersresearch.com/research/stj/mw-is-short-stj/

  3. Bour, G., Moe, M.E.G., Borgaonkar, R.: Experimental security analysis of connected pacemakers. In: Roque, A.C.A., Fred, A.L.N., Gamboa, H. (eds.) Proceedings of the 15th International Joint Conference on Biomedical Engineering Systems and Technologies, BIOSTEC 2022, Volume 1: BIODEVICES, Online Streaming, 9–11 February 2022, pp. 35–45. SCITEPRESS (2022). https://doi.org/10.5220/0010816900003123

  4. Bour, G.N.: Security analysis of the pacemaker home monitoring unit: a blackbox approach. Master’s thesis, NTNU (2019)

    Google Scholar 

  5. Camara, C., Peris-Lopez, P., Tapiador, J.E.: Security and privacy issues in implantable medical devices: a comprehensive survey. J. Biomed. Inform. 55, 272–289 (2015)

    Article  Google Scholar 

  6. CISA: ICS Medical Advisory (ICSMA-20-170-05) (2020). https://us-cert.cisa.gov/ics/advisories/icsma-20-170-05. Accessed 30 Sept 2021

  7. Denning, T., Fu, K., Kohno, T.: Absence makes the heart grow fonder: new directions for implantable medical device security. In: HotSec (2008)

    Google Scholar 

  8. Digital, N.: A clear and present danger (2022). https://digital.nhs.uk/features/a-real-and-present-danger

  9. Europol: Covid-19 sparks upward trend in cybercrime (2022). https://www.europol.europa.eu/media-press/newsroom/news/covid-19-sparks-upward-trend-in-cybercrime

  10. Færestrand, S.: Telekardiologi for jernmonitorering av pacemaker og icd (2010). https://www.legeforeningen.no/contentassets/4896657d08894a6886de725113d89de4/hjerteforum3-2010web08telemedisin.pdf

  11. Golde, N., Feldmann, A.: SMS vulnerability analysis on feature phones. Master’s thesis (2011)

    Google Scholar 

  12. Halperin, D., et al.: Pacemakers and implantable cardiac defibrillators: software radio attacks and zero-power defenses. In: 2008 IEEE Symposium on Security and Privacy (SP 2008), pp. 129–142. IEEE (2008)

    Google Scholar 

  13. Secure design best practice guide (2020). https://www.iotsecurityfoundation.org/wp-content/uploads/2019/03/Best-Practice-Guides-Release-1.2.1.pdf

  14. ISECOM: OSSTMM. https://www.isecom.org/OSSTMM.3.pdf

  15. Justis- og beredskapsdepartementet, Helse- og omsorgsdepartementet: Forskrift om medisinsk utstyr (2005). https://lovdata.no/dokument/SF/forskrift/2005-12-15-1690/%2FT1%2Ftextsection1-5#/T1/textsection1-5

  16. Kok, J.S., Markussen, B.A.: Fuzzing the pacemaker home monitoring unit. Master’s thesis, NTNU (2020)

    Google Scholar 

  17. Li, C., Raghunathan, A., Jha, N.K.: Improving the trustworthiness of medical device software with formal verification methods. IEEE Embed. Syst. Lett. 5(3), 50–53 (2013)

    Article  Google Scholar 

  18. Lie, A.W.: Security analysis of wireless home monitoring units in the pacemaker ecosystem. Master’s thesis, NTNU (2019)

    Google Scholar 

  19. Marin, E., Singelée, D., Garcia, F.D., Chothia, T., Willems, R., Preneel, B.: On the (in) security of the latest generation implantable cardiac defibrillators and how to secure them. In: Proceedings of the 32nd Annual Conference on Computer Security Applications, pp. 226–236 (2016)

    Google Scholar 

  20. Mulliner, C., Golde, N., Seifert, J.P.: SMS of death: from analyzing to attacking mobile phones on a large scale (2011). https://www.usenix.org/conference/usenix-security-11/sms-death-analyzing-attacking-mobile-phones-large-scale

  21. OWASP embedded application security (2020). https://owasp.org/www-project-embedded-application-security/

  22. Rasmussen, K.B., Castelluccia, C., Heydt-Benjamin, T.S., Capkun, S.: Proximity-based access control for implantable medical devices. In: Proceedings of the 16th ACM Conference on Computer and Communications Security, pp. 410–419 (2009)

    Google Scholar 

  23. Rios, B., Butts, J.: Security evaluation of the implantable cardiac device ecosystem architecture and implementation interdependencies (2017)

    Google Scholar 

  24. Rostami, M., Juels, A., Koushanfar, F.: Heart-to-heart (H2H) authentication for implanted medical devices. In: Proceedings of the 2013 ACM SIGSAC Conference on Computer & Communications Security, pp. 1099–1112 (2013)

    Google Scholar 

  25. Savci, H.S., Sula, A., Wang, Z., Dogan, N.S., Arvas, E.: Mics transceivers: regulatory standards and applications [medical implant communications service]. In: Proceedings of the IEEE SoutheastCon, pp. 179–182. IEEE (2005)

    Google Scholar 

  26. Schechter, S.: Security that is meant to be skin deep using ultraviolet micropigmentation to store emergency-access keys for implantable medical devices (2010)

    Google Scholar 

  27. Weinmann, R.P.: Baseband attacks: remote exploitation of memory corruptions in cellular protocol stacks. In: WOOT, pp. 12–21 (2012)

    Google Scholar 

  28. Zheng, G., Shankaran, R., Orgun, M.A., Qiao, L., Saleem, K.: Ideas and challenges for securing wireless implantable medical devices: a review. IEEE Sens. J. 17(3), 562–576 (2016)

    Article  Google Scholar 

  29. Zheng, G., et al.: Finger-to-heart (F2H): authentication for wireless implantable medical devices. IEEE J. Biomed. Health Inform. 23(4), 1546–1557 (2018)

    Article  Google Scholar 

  30. Zheng, G., Zhang, G., Yang, W., Valli, C., Shankaran, R., Orgun, M.A.: From WannaCry to WannaDie: security trade-offs and design for implantable medical devices. In: 2017 17th International Symposium on Communications and Information Technologies (ISCIT), pp. 1–5. IEEE (2017)

    Google Scholar 

Download references

Acknowledgments

We very much appreciate the contributions of Éireann Leverett that did some of the initial hardware testing to discover the HMU debug interfaces. Finally, we are grateful to Snorre Aunet and Ingulf Helland from NTNU who took time to help us solder a connector on the HMU.

This work was funded by Reinforcing the Health Data Infrastructure in Mobility and Assurance through Data Democratization, a five-year project (grant number 28885) under the Norwegian IKTPLUSS-IKT and Digital Innovation programme. The authors gratefully acknowledge the financial support from the Research Council of Norway.

Author information

Authors and Affiliations

  1. SINTEF Digital, Strindvegen 4, Trondheim, Norway

    Guillaume Bour & Ravishankar Borgaonkar

  2. Norwegian Police IT Services, Oslo, Norway

    Anniken Wium Lie

  3. Techfolk, Oslo, Norway

    Jakob Stenersen Kok

  4. Bekk, Oslo, Norway

    Bendik Markussen

  5. Norwegian University of Science and Technology, Trondheim, Norway

    Marie Elisabeth Gaup Moe

Authors
  1. Guillaume Bour
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anniken Wium Lie
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jakob Stenersen Kok
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Bendik Markussen
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Marie Elisabeth Gaup Moe
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ravishankar Borgaonkar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Guillaume Bour .

Editor information

Editors and Affiliations

  1. Universidade Nova de Lisboa, Caparica, Portugal

    Ana Cecília A. Roque

  2. Virginia Tech, Blacksburg, VA, USA

    Denis Gracanin

  3. University of Vienna, Vienna, Austria

    Ronny Lorenz

  4. University of Edinburgh, Edinburgh, UK

    Athanasios Tsanas

  5. Université de Montréal, Montréal, QC, Canada

    Nathalie Bier

  6. Instituto de Telecomunicações and Instituto Superior Técnico - Lisbon University, Lisbon, Portugal

    Ana Fred

  7. Nova School of Science and Technology and University of Lisbon, Caparica, Portugal

    Hugo Gamboa

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this paper

Check for updates. Verify currency and authenticity via CrossMark

Cite this paper

Bour, G., Lie, A.W., Kok, J.S., Markussen, B., Moe, M.E.G., Borgaonkar, R. (2023). Security Analysis of the Internet of Medical Things (IoMT): Case Study of the Pacemaker Ecosystem. In: Roque, A.C.A., et al. Biomedical Engineering Systems and Technologies. BIOSTEC 2022. Communications in Computer and Information Science, vol 1814. Springer, Cham. https://doi.org/10.1007/978-3-031-38854-5_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-38854-5_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-38853-8

  • Online ISBN: 978-3-031-38854-5

  • eBook Packages: Computer ScienceComputer Science (R0)

Publish with us

Policies and ethics

Search

Navigation