# Multilevel Privacy Assurance Evaluation of Healthcare Metadata
## 3 Multilevel Privacy Assurance Evaluation: Results and Evaluation
### At Individual Level: Results and Evaluation
#### 3.1.1 Results  
As an element of consumerism and service-dominant logic [76], the value chain starts with the healthcare consumers, i.e., the patients. Thus, the healthcare consumers, as the market segment of patients, are the principal. The principal utilizes the postulates of privacy by policy, privacy by design/architecture, and the patient's informed consent; see Figure 3. Principal at the onset of ailment delegates the duty to the agents (i.e., healthcare provider). In return, the principal provides his or her PII to agents while interacting with them. In an ideal patient value-care scenario, if a principal offers his or her sensitive personal info to other value actors, the privacy is a common (intrinsic) factor that he or she expects in return alongside other tangible healthcare outcomes. Agent, on the other hand, performs the assigned duty in a confined period called contract [77]. In this wake, the outcome-oriented contracts are most efficient as they co-align the agents' priorities with that of the principal regarding risk-sharing. This co-alignment originates rewards for the agents by providing value care to principal [77]. For example, the Statement of Applicability (ISO 27001 Clause 6.1.3 d) links the risk assessment and treatment and the implementation of information security. Similarly, a transparent information system also serves the principal as it reveals the agents' undertakings from the beginning of the contract [77]. According to the international (ISO27001) and the Dutch (NEN7510) standards for Information Security Management Systems (ISMS), the Netherlands were certified for Transparency in Healthcare (TiH) On 7 September 2015. Transparency in Healthcare (TiH) meets the highest standards for data security and regulatory compliance [78]. However, some Dutch healthcare providers are in the lead concerning TiH than the rest. For example, hospitals usually make a transparency window with the patients for patients' satisfaction, but the rest of the caregivers, including GPs, lag far behind in this. Regulators are divisible into two types. One type of regulator gives accreditations based on global and national standards (i.e., ISO and NEN) to the healthcare providers based on their compliant behaviors. The other type comprises independent agency and regulatory authority like Inspecting Gezondheidzorg jeugd (IGJ) and Nederlandse ZorgAuthoriteit (NZA), respectively. IGJ performs the oversight tasks, whereas NZA remotely regulates and facilitates competition in the highly disintegrated Dutch healthcare market [9]. This type of regulator has powers to ask for compensations based on noncompliant behavior [12]. The third party is the value actor who is not directly involved with the principal but facilitates the agent in efficiently executing value transactions with the principal, for example, the pharmaceutical manufacturers, system-based machine vendors to healthcare providers. The value transactions take place as core and counter-value activities. Core activities are the initiating activities of value actors. By contrast, counter activities are  
Figure 3: Privacy assurance evaluation at individual-level. response-based activities. The value activities with the regulators are proof and counter activities. The proof includes the proof of performance to the regulator by healthcare providers concerning privacy preservation. The counter activity includes the confidence in healthcare providers' information security from the regulator. During value transfers, for patients, there is an outflow of data-carrying personal sensitive info of the patient to the domain-specific healthcare providers such as GPs, pharmacy, hospital+EHBO, diagnostic lab (biobank and biorepository), and health insurance company. There is an inflow of healthcare services to the patients. Additionally, there is an expected inflow of privacy as a (subjective) value object to healthcare consumers.