By Meredith Alexander Kunz

For three days recently, Stefanos Zenios sat in a room in San Francisco General Hospital watching a doctor and nurse perform colonoscopies. Peering through his half-rim glasses as test after test was conducted, he wrote copious notes in hopes of understanding why the test was available to so few of the public hospital's patients.

Zenios is the Charles A. Holloway Professor of Operations, Information, and Technology at the Business School, a GSB Trust Faculty Fellow for 2009-10, and a professor, by courtesy, in Stanford's Department of Bioengineering. In business schools, operations faculty normally are experts in fixing supply chains or customer service lines. Zenios hangs out with physicians, engineers, venture capitalists, and makers of medical equipment because he is passionate about slaying dragons within health care delivery systems. Those dragons are the written and unwritten rules that constrain how hospitals, clinics, insurance companies, regulators, and manufacturers of medical products choose medical technologies and, indirectly, the patients who get access to them.

"I believe new technologies, if combined with new policies that reward providers for quality care, will improve medical outcomes at better prices than we have today," he says.

Believing is not enough, however, and Zenios acts on two tracks. Since 2005, he has worked with other Stanford faculty to train a new generation of businesspeople, doctors, and engineers in medical innovation. A two-quarter Biodesign Innovation course, a related year-long fellowship program, and now a textbook (see related story: Guidebook for Biodesign Innovation) serve his overall goal of teaching others how to make health care more effective and accessible to more people.

His second approach is to continue his own research into improving access to health care. Already Zenios has been instrumental in expanding HIV testing in poor countries and the availability of organs for transplant in the United States. Health care is the "perfect" application of operations research, he says, because its systems are "plagued by access problems driven by inefficiencies. These result when people, technology, and information are not coordinated." By using data gathered from the real world and analyzing it with mathematical and economic models, he can recommend changes to improve coordination and access.

Cyprus-born Zenios jokes that his wife calls him a "pseudo-doctor." As a child he wanted to become a doctor, but his father encouraged him to pursue math, a field where he shined. At Cambridge University, Zenios focused on "applicable math," mathematics applied to the social sciences.

He first encountered mathematical modeling for health care at Massachusetts Institute of Technology while pursuing a PhD and working with Professor Lawrence Wein, now the Stanford Business School's Paul E. Holden Professor of Management Science. Wein asked Zenios to help refine HIV testing. In countries where health care providers could not afford to test every person's blood separately, doctors wanted to pool samples as a first screening step in locating infections, but it wasn't a simple change -- the test would need to be recalibrated mathematically to ensure correct results.

Zenios' first modeling attempts were unsuccessful. Then Constantia Petrou, a fellow Cypriot who was a PhD student at the School of Public Health at rival Harvard and another bridge into the medical world for Zenios, suggested ways to improve the model. He experimented more; the model worked and led to a test with improved accuracy. He was hooked on health care.

"I learned how to model something with social value, and how to work with [medical] experts to develop mathematical models," he says. He also formed a lasting bond with Petrou: The two married and are parents to 12-year-old daughter Panayiota and 7-year-old son Andreas. Petrou earned an MBA from Stanford in 2002, and today Zenios is a consultant to her company, Culmini, which develops web tools to help patients and their families cut through information clutter and discuss with their doctor what to do to get a successful treatment.

When Zenios began to study the kidney transplant waiting list with Glenn Chertow, now a professor at Stanford Medical School, he modeled ways of organizing organ transplants to see how they affected access and outcomes. The work provided the template for subsequent efforts by the U.S. transplant community to improve the organ allocation system. Later he collaborated with Lainie Ross at the University of Chicago Medical Center on an effort to change the ground rules for kidney exchanges, the networks that help people find a kidney match more quickly, by introducing more flexibility into the transplant waiting list.

For instance, a patient may have a relative willing to donate a kidney, but that kidney is not a tissue match. Under Zenios' and Ross' flexible rules, the relative could give the kidney to a stranger on the waiting list. Then the first patient could gain a higher priority for the next available match. The problem is that in some cases the higher priority patient displaces another patient who ends up waiting longer, something that would violate the ethical principle of "first do no harm" and would reduce the second patient's access to transplantation. Zenios and Ross identified the cases under which this would happen and introduced guidelines to ensure that such exchanges did not occur. Current kidney exchanges operate under these guidelines, and an unprecedented eight-way kidney swap occurred in July.

 Zenios acknowledges that the technologies he studies and the process he co-teaches in the Biodesign Innovation course "address the needs of a well-insured population." What about those who are not insured or whose patchy coverage won't pay $20,000 for a new device? Today the U.S. health care system as a whole seems to be in critical condition, a victim of its rising costs and diminishing number of insured Americans.

With 50 million people under- or uninsured, he says, "we need to modify the biodesign process to develop devices that can be used in constrained settings" such as public hospitals and clinics. That is why he began working recently on a project with the California Health Care Foundation aimed at helping innovators concentrate on developing devices that would be affordable both for patients with sufficient insurance coverage and for the underinsured or uninsured. Which takes us back to the colonoscopies. The procedure itself is not new, but at a June workshop for venture capitalists, medical tech developers, and foundation leaders, Zenios suggested what aspects of the technology needed to change to improve access.

The current process requires a physician to control the scope and a nurse to assist by monitoring the patient's vital signs. Whenever a polyp is discovered, the physician has to stop while the nurse uses a forceps to take a biopsy. Zenios wondered: Could a new technology enable one person to perform all tasks?

"If we could do that, we could do twice as many colonoscopies -- double capacity," he says. That would enable public hospitals to more broadly screen for colon cancer and other intestinal diseases. Now San Francisco General has only enough resources to test patients with a suspected problem. Equally or more important, Zenios points out, such a technology change would also be attractive for health care providers that serve patients with insurance. The California Health Care Foundation has extended funding to the pilot to enable more comprehensive analysis of the technological needs of public hospitals and how these needs can be addressed using the biodesign process.

In September 2009, Zenios introduced an MBA seminar, Field Trips to Grassroots Innovators in Health Care: Improving Access and Outcomes for the Underserved. In it, he asks students to examine devices and information systems created by health care providers for their uninsured patients and come up with ways to market these products profitably. One promising idea: a streamlined electronic referral system that could help patients see specialists more quickly.

 The real problem behind the rising health care costs and exploding numbers of uninsured, he says, is not pricey technology but the incentives driving their use. "Right now, the only viable [business] model for innovators is selling more devices, selling more drugs," he says. This means commercially viable technologies are the ones that increase the number of procedures performed, not the ones eliminating procedures or making procedures more efficient. This improves outcomes for patients but it drives up costs.

If, instead, doctors could be paid for health results, they could focus more on the big picture -- improving their patients' outcomes overall with the least waste of resources.

"Providers need to get rewarded for quality of care. This will improve outcomes, reduce waste, and create incentives for innovators to develop new types of technologies," Zenios says. It's a topic he explores in his MBA course Medical Technologies: From Innovators to Providers and Patients.

Change may be coming as medical payers develop new reimbursement plans. Already, "both the government and insurers are experimenting with pay for performance," he says.

As the health care system's incentive problems become more obvious through public debate, says colleague and co-teacher Professor Paul Yock, Zenios is "the right guy at the right time."