Table 2 Description of threats

q1

Sound quality with mobile phone videoconferencing is usually worse than regular calls between mobile phones. Reasons include poor bandwidth and mobile phones usually in loudspeaker mode during video calls, often with disturbing background noise. This may result in misunderstandings, lost information and delays.

q2

Poor image quality is a common problem with video calls from mobile phones. Although likely to improve with improved technology, camera shake, poor light and weather conditions will influence on the image quality. Some image quality problems are due to current methods for video compression.

q3

The caller may believe that the image is a sufficient description, therefore not describing the situation appropriately, which leads to misinterpretations.

q4

The dispatcher may believe the image describes the situation sufficiently, and therefore do not ask for important information, which leads to misinterpretations.

q5

When there are several patients in the same accident or emergency, it is possible to mix-up images from one patient to what is said about another patient. The image may clarify or complicate matters when much information needs to be sorted out.

a1

It usually takes more time to establish a phone call with video. Today this is usually a matter of a few seconds, time which may be saved in successful guidance trough video communication. The caller may however be negatively affected by delays during initiation of contact with the EMCC, which in turn may affect how the case is handled.

a2

The capacity of mobile phone networks is often reached during larger accidents. Videoconferencing demands more bandwidth than audio communication, which may be a problem when many people are calling at the same time. In some mobile networks video calls use a reserved bandwidth, not interfering with the bandwidth used for audio calls. Depending on traffic and network configuration, it can be easier or more difficult to make a call go through when using video calls.

a3, a4, a5

EMCCs commonly have audio logs of all communication with the public for playback. If the connection with the caller is lost and cannot be reestablished, audio playback may provide essential information to solve the emergency. Audio logs can also be useful for debriefing, or when questions later arise if the EMCC should have handled a case differently. If, for some reason, the log is not available, it may negatively affect patients in cases where connection is lost (threat a3). It may negatively influence the organization if logs are not available for documentation (threat a4) or debriefing (threat a5). There are several causes for these threats to occur, either that video is not recorded by default implementation, that playback of videorecordings is difficult, or that such recordings are corrupted or destroyed.

a6

Mobiles used for videoconferencing is kept out from the body and has greater exposure to weather conditions such as rain and cold temperatures. This may cause equipment failure and loss of connection.

a7

Technical difficulties because of less stable connection during mobile videoconferencing can delay or disrupt the exchange of information.

a8

Videoconferencing drain more battery on mobile phones than does audio communication. Use of video may therefore cause more lost connections. With empty batteries, communication can not be reestablished.

a9

In some situations the dispatcher may want to forward the call to another dispatcher either within the same EMCC or in a different EMCC. If this is not possible during video calls, the dispatcher may shut down the call and establish an audio call instead. This comes with a risk of wasting time.

c1

Telephone communication can be wiretapped. While it takes more advanced technology and skills to wiretap a live videoconference over a mobile network, the public interest in images from emergencies suggest increased willingness to invest in such technology.

c2

Stored images are likely to be of greater interest and may contain more sensitive patient information than audio logs. Stored video and images may therefore increase attempts of unauthorized access.

c3

If visitors are allowed into the EMCC, or the images on computer screens can be observed by people outside the EMCC, this may reveal patient sensitive information. This threat is dependent on local conditions such as placement of computer screens and access restrictions to the EMCC.

No threats to data integrity were identified.

m1

With two-way videoconferencing the caller may identify the dispatcher. Dispatchers have been concerned that the loss of identity protection makes them more vulnerable to insults [7].

m2

The EMCC is a demanding work environment, and the introduction of videoconferencing may distract or increase demands on dispatchers. In the worst case, this may cause inefficiency or delays.

m3

The caller may focus on filming rather than helping the patient. The dispatcher may ask for images, and disturb or interrupt the treatment the caller otherwise would have initiated. Similar concerns were also raised when resuscitation instructions first was provided by telephone [29].