  Integrated healthcare systems require the transmission of medical images
between medical centers. The presence of watermarks in such images has become
important for patient privacy protection. However, some important issues should
be considered while watermarking an image. Among these issues, the watermark
should be robust against attacks and does not affect the quality of the image.
In this paper, a watermarking approach employing a robust dynamic secret code
is proposed. This approach is to process every pixel of the digital image and
not only the pixels of the regions of non-interest at the same time it
preserves the image details. The performance of the proposed approach is
evaluated using several performance measures such as the Mean Square Error
(MSE), the Mean Absolute Error (MAE), the Peak Signal to Noise Ratio (PSNR),
the Universal Image Quality Index (UIQI) and the Structural Similarity Index
(SSIM). The proposed approach has been tested and shown robustness in detecting
the intentional attacks that change image, specifically the most important
diagnostic information.
