A Non-Embedding Watermarking Framework Using MSB-Driven Reference Mapping for Distortion-Free Medical Image Authentication

Ensuring the integrity of medical images is essential to securing clinical workflows, telemedicine platforms, and healthcare IoT environments. Existing watermarking and reversible data-hiding approaches often modify pixel intensities, reducing diagnostic fidelity, introducing embedding constraints, or causing instability under compression and format conversion. This work proposes a distortion-free, non-embedding authentication framework that leverages the inherent stability of the most significant bit (MSB) patterns in the Non-Region of Interest (NROI) to construct a secure and tamper-sensitive reference for the diagnostic Region of Interest (ROI). The ROI is partitioned into fixed blocks, each producing a 256-bit SHA-256 signature. Instead of embedding this signature, each hash bit is mapped to an NROI pixel whose MSB matches the corresponding bit value, and only the encrypted coordinates of these pixels are stored externally in a secure database. During verification, hashes are recomputed and compared bit-by-bit with the MSB sequence extracted from the referenced NROI coordinates, enabling precise block-level tamper localization without modifying the image. Extensive experiments conducted on MRI (OASIS), X-ray (ChestX-ray14), and CT (CT-ORG) datasets demonstrate the following: (i) perfect zero-distortion fidelity; (ii) stable and deterministic MSB-class mapping with abundant coordinate diversity; (iii) 100% detection of intentional ROI tampering with no false positives across the six clinically relevant manipulation types; and (iv) robustness to common benign Non-ROI operations. The results show that the proposed scheme offers a practical, secure, and computationally lightweight solution for medical image integrity verification in PACS systems, cloud-based archives, and healthcare IoT applications, while avoiding the limitations of embedding-based methods.