by Cheryl Clark
By random and unscientific measure, about one in 10 people in line to buy an iPad at a San Diego Apple Store Saturday were health providers hoping to use it for patient care.
Kevin Kaloha, an intern at nearby UCSD School of Medicine, said he was in line on orders from his Radiology Department chiefs. "They told me to come down here and buy one," he said. "I think they want to test it and try it out to see how we can use it for imaging."
Hal Meltzer, a pediatric neurosurgeon at Rady Children's Hospital, was also eager to test it out in his practice. But he isn't quite ready to bring it into the operating room.
Eventually, he thinks he and other doctors will use it, especially because its toy-like appearance may help explain medical issues to children in a less scary way.
"There's so many possibilities," said the neurosurgeon, who hopes that the device will save trips to the computer monitor to review MRI or CT images. And then there's the hospital, which can use the iPad to communicate with a doctor when his or her patient is in the emergency room.
A key is how the iPad handles EMR or EHR software applications available from Epic, Allscripts or other vendors, many of the physicians said.
Randy Hawkins, a neurologist and chief information officer for Sharp Rees-Stealy Medical Group's 450 doctors, hopes he can use technical "work-arounds" with Citrix or other applications to get the iPad to understand speech.
"I can do that now with my tablet PC, but it's clunky. It's my goal to have a handheld device I can talk to," he said.
Also, Hawkins said, he thinks using an iPad to take notes for patient histories will be faster than turning to his laptop or office-based computer.
Apple's technology isn't quite there for EMR, he says, a fact that he says was "disappointing. It's not yet what we need. I can't use the word ‘slick' and I won't use it until I can." For now, he's buying the device to watch movies.
Maureen Gibbins Paolini, who teaches ethical conduct in research at San Diego State, said the iPad will be useful for patient consent forms and for educating patients about clinical trials. "It encourages interaction," she said.
Theresa Gillete, an X-ray technician at Sharp Memorial's outpatient Pavilion, plans to try it out to look up imaging references. "I'm tired of carrying around a laptop on my back to and from work," she said.
And Greg Steele, an optometrist with a large group practice, thinks the iPad has great promise for certain eye exams. He doesn't know whether his medical group would see it that way, but found hope while standing in line.
"I'm just now seeing the main doctor who's in charge of the medical staff right there in line ahead of us. So maybe there's hope," he said with a laugh.
by Daniel Palestrant, MD
After the debate has ended and the lobbyists have moved on to their next clients, health care will be left the way it started, a physician and a patient sitting in a room trying as best as they can to prolong health and forestall sickness. Fortunately the many victories and losses claimed by both ends of the political spectrum will not change this shared pursuit.
So then why has reform that promises to get millions more in a discourse with their doctors been so polarizing? Making sure more Americans have health insurance can only be a major victory, right? Too bad the medical establishment is not celebrating. In fact, the mood in those exams rooms is downright morose.
In tens of thousands of exam rooms all over the country physicians are struggling to make sense of the 2,000-plus pages of the reform bill. A recently released poll of more than 2,000 physicians, conducted by Athenahealth and Sermo, is alarming. The poll, part of a broader Physician Sentiment Index, indicates that 79% of physicians are less optimistic about medicine since the passage of health care reform. Fifty-three percent indicate they will consider opting out of insurance plans with passage of the bill. Worst of all, 66% indicate that they will consider opting out of all government-run programs. The same reform bill that will provide "care for all" may drive away more physician caregivers than attract previously uninsured patients. What a predicament that would be.
Many may find the data from the poll puzzling. How could physicians be so pessimistic about a bill that clearly has so many positives? For one, the bill addresses none of the issues most consistently ranked by physicians as the most critical for lowering costs and improving access. Tort reform, streamlining billing and payment, and fixing the flawed government formula for calculating physician reimbursement are given little, if any, serious attention.
What physicians knew then and certainly know now is that instead of fixing these issues, the government will be forced to take the path of least resistance to save money (that is to say the path with the least special interest resistance). That means reducing physician reimbursement, just as the country is counting on even more physicians to be available.
Physicians knew the health care bill had a "gotcha" buried deep inside. The only way it could be called "budget-neutral" was to implement significant reductions in physician payments. So just as we are hoping more physicians become available to treat the influx of 31 million more patients, the government is implementing a massive reduction in physician reimbursement (a 21% reduction in physician reimbursement went into effect April 1 after several years of no adjustments for inflation, meaning physician reimbursement has been declining for several years already).
In a moment of complete legislative hypocrisy, the proponents were touting one health care bill that included cost estimates that assumed a massive reduction in payments while another bill moved its way through Congress that would reverse those cuts (the bill reversing the cuts was ultimately defeated, meaning the cuts did go into effect). At some point, basic supply and demand will kick in, and there will be insufficient physician resources for treating patients.
But what of the much-touted American Medical Association's support for the bill? The AMA, which counts less than 10% of its $300 million dollars in revenue from physician membership dues (the rest comes from a government sanctioned monopoly whereby the AMA sells the billing codes upon which the entire health care system relies) had little choice but to endorse the bill, lest the government retract its exclusive license on billing codes. Again physicians know what the public does not: Less than 15% of practicing physicians are AMA members, so any AMA support is more a reflection of the AMA's financial interests than what physicians in this country truly want. This is a situation that proved opportunistic to proponents of the bill but could prove painful for America's health care system.
Indeed this might be a pyrrhic victory. Health care without active physician participation is no health care at all. Many physicians are investing in electronic health records and billing technologies that alleviate some of the huge administrative brunt that threatens the independent medical office and enables them to fare better in the uneven fight with insurers. These technologies do hold great promise in ensuring these projections remain just that, projections, and not reality.
But still, as the Athenahealth-Sermo poll shows, many physicians are ultimately faced with the choice of opting out of government insurance programs or going out of business. A significant number of physicians are realizing they cannot stay in business--let alone remain independent--if they continue to accept artificially low government reimbursement rates.
Many states are recognizing this impending crisis, and rather than addressing the causes of medical inflation are resorting to an "easy," short-sighted fix: Make participation in state and federal insurance programs a condition of medical licensure. Far from a theoretical proposition, Massachusetts' health care system is so over budget that the state legislature is considering a bill that would mandate physician participation, in effect making physicians state employees.
Can anyone say socialized medicine?
by Gienna Shaw
The devices, treatments, and procedures that will change the delivery-and the business-of healthcare.
Forget flying cars, cities crisscrossed with moving sidewalks, and unisex body suits made of silver lame. Instead, get ready for an explosion in smart medical devices, infection-fighting nanotechnology, virtual biopsies and colonoscopies, bionic organs, and operating rooms that could serve as a backdrop for a science fiction movie. These and other medical breakthroughs are more than cool. They're going to change the way hospitals provide care to their patients and how they do business. New and emerging technology will dramatically improve outcomes, save money, reduce readmission rates, help hospitals recruit and retain physicians, build your organization's reputation, and more.
OK, they're pretty cool, too.
Smart medicine
These days it seems everything is smart. There's the ubiquitous smartphone, of course. But soon there will also be smart bandages that monitor vital signs, smart prescription bottles that remind the patient when to take a pill, and smart pedometers that count the patient's steps and, like smart little tattletales, send the results to the physical therapist. But perhaps the best example of smart technology is the smart OR. Previously found in just a few large academic medical centers, the technology is starting to show up in community hospitals, too.
The array of tools in the smart surgical suite at the 344-licensed-bed Sacred Heart Hospital in Eau Claire, WI, includes a navigational device that's like GPS for the brain and four 57-inch plasma screens that allow the whole team to see what's going on at any stage of the operation-in high-def 3-D. (See "Features of Sacred Heart's Smart OR," below.)
"We're relying on technology much more than we ever have before [with the] singular purpose of making brain and spine surgery more effective," says Kamal Thapar, MD, director of the brain and spine institute and director for tertiary care at Sacred Heart, as well as a neurosurgeon with Marshfield Clinic. "It's had a profound impact on patient care."
The biggest effect is on clinical quality. Navigational tools allow surgeons to make the smallest possible incisions, resulting in faster recovery time and allowing the team to treat sicker, older, and more fragile patients. An intra-operative MRI allows surgeons to examine a patient while he or she is still in the OR to make sure all of the tumor has been removed and helps reduce reoperation rates. The most common question a patient and his or her family asks after surgery is, "Did you get all of the tumor?" Surgeons used to have to say, "I think so," says Thapar. In-suite imaging changes that.
Screw malposition rates are just one example of how the technology is improving outcomes. If medical screws used to stabilize the spine are not positioned correctly, the results can be fatal, so most patients must undergo a second surgery to fix poor placement. The average screw malposition rate is about 5%. Thapar's freehand screw malposition rate was about 2.5%. After the hospital started using the smart technology, the screw malposition rate dropped to less than 0.1%. The reoperating rate went from 15% to 0%.
"This was the first time in my entire career I achieved a zero anything," Thapar says. The technology also aids physician recruitment, says Steve Ronstrom, president and CEO of Sacred Heart. "We made a decision to really get a comprehensive and high-quality neurosurgical program here," he says. "The way we were going to compete is to attract the very best doctors to our community."
But the smart OR didn't just help Sacred Heart attract surgeons in the midst of a specialist shortage, Ronstrom says. It also allowed the organization to hire surgeons who were willing do charity care, perform both complicated and bread-and-butter cases, and even cover the ER.
It's had a ripple effect on the entire organization and its culture, Thapar says. It's changed how the hospital thinks about itself and also how others perceive the organization. "There's no question that this is the way things are going to go. There's just no doubt in my mind," says Thapar. "This technology became the catalyst for change . . . and we just won't be going back."
What's Next: How do you prepare for a project as ambitious as this one? "Plane tickets are the best investment we can make," Ronstrom says. Visiting other organizations with similar technology allowed Sacred Heart to learn from others' mistakes and challenges. Even the smallest details-such as the positioning of a patient headrest-can be a big issue. "The devil's in the details," Ronstrom says.
Nanomedicine
Nanotechnology itself is not new-it's already being used to make sports equipment lighter and to make computer chips faster, for example. But there are some new medical applications in the pipeline, according to the National Nanotechnology Initiative, which coordinates federal nanotechnology research and development funding. Drugs that use nanoparticles to deliver toxins directly to tumors, minimizing damage to healthy tissue, are now in trials. Nanotechnology could make imaging tools work better and more safely. And gold nanoparticles can be used to detect early stage Alzheimer's.
Researchers at the University of Michigan and Roswell Park Cancer Institute are studying a treatment that uses nanoparticles to better visualize brain tumors during surgery, improve brain tumor resection, and eradicate residual tumor cells. To do this, they are designing tissue-staining nanoparticles that will be selectively internalized by brain cancer cells. The nanoparticles, which specifically target cancer cells, will be linked to both a dye and a therapy agent. The dye will allow surgeons to visualize the tumor during surgery, facilitating more complete resection, according to the National Institute of Biomedical Imaging and Bioengineering. Following removal of the bulk of the tumor, the light-activated therapeutic agent would be stimulated by laser light to kill the remaining tumor cells.
Infection control is another area where nanotechnology shows promise. For example, scrubs and lab coats made by Vestagen Technical Textiles of Orlando, FL, repel liquids as watery as wine or as viscous as ketchup. The fibers are impregnated with nano-sized silicone particles that change the surface area of the fabric, increasing tension and creating a barrier to fluids such as blood and vomit. The material also has antimicrobial properties with a rapid kill time-99.9% of microbes are eradicated in fewer than 10 minutes, compared with consumer-market materials such as those used in athletic gear that can take up to 24 hours to eradicate microbes. The scrubs are in trials at Virginia Commonwealth University's Medical College of Virginia and at Washington Hospital Center. Vestagen is awaiting FDA approval for its efficacy claims.
"There's no question if you culture curtains or ties or coats you find organisms," says Richard Wenzel, MD, professor and former chairman of the department of internal medicine at VCU. "It's not solidly proven yet how much organisms are transferred from a physician's clothes to a patient."
Combining the two mechanisms-the antimicrobial to kill on contact and the nanotechnology to repel liquids-shows promise for protecting healthcare workers from acquiring of nosocomial pathogens, says Thomas J. Walsh, MD, adjunct professor at the University of Maryland School of Medicine who, in collaboration with colleagues Shmuel Shoham, MD, and Matthew Hardwick, PhD, is conducting lab and clinical studies of the product at Washington Hospital Center, a 926-licensed-bed teaching hospital in Washington, DC.
"It's a multipronged approach. No one measure is going to be successful," he says. "Bacteria and fungi are very adherent organisms," he adds, and there could be a "substantial reduction of organism acquisition on the engineered fabric."
What's Next: Scientists are still researching the impact of nanotechnology on infection control, but in the meantime, Wenzel advises hospital leaders to embrace new and emerging infection control measures. "It will save you a lot of money, it will save you lawsuits, it will save you bad publicity, and you'll have bragging rights for low infection rates," he says.
Wireless medicine
Healthcare organizations are already using wireless technology to remotely monitor patients and transmit large imaging files. But the devices will soon be much smaller, more convenient, and have a higher sampling rate. One emerging wireless technology is the smart or wireless bandage. Patients simply peel off the backing and stick it on their skin like a nicotine replacement patch. The disposable medical device has a processor to monitor vital signs, which are transmitted to a processing service.
Current boxlike models that connect to a phone line send out a patient's vitals once or twice a day-assuming the patient complies. The new technology can take and send thousands of data samples daily. And the devices are passive: The patient's compliance is met just by putting the bandage on.
What's Next:Wireless devices and telehealth are among the most frequently cited examples of technology that will change how healthcare is delivered. Among the benefits: They speed diagnosis, intervention, and therapy; they produce more data and lead to better outcomes; and they're more efficient.
One wireless device in the pipeline could improve medication compliance. It fits onto a prescription bottle and alerts patients when it's time to take their pills-and reminds them if they forget. In trials now at the Center for Connected Health, the device senses when a patient unscrews the cap on the prescription bottle and sends the information through a secure network to an online site. "I'm using it myself and I find it very helpful," says Joseph C. Kvedar, MD, director of the center, a division of Partners HealthCare in Boston.
"Adherence to medication alone can lower costs," Kvedar says. "It's a powerful tool, and just about every person should have some kind of medication device when we get them to the point where they're affordable and reliable." As accountable care, bundled payments, and pay-for-performance become more common, improving health outcomes with wireless technology and other tools and devices makes business sense, Kvedar says. Partners is also using such cutting-edge technology to differentiate itself in the marketplace, he adds.
What's Next: The technologies of tomorrow can impact your purchasing decisions today. Hospitals should hold off on investing in hardwired connectivity and save the money-and the disruption, expense, and contamination risk-if you can.
Medical imaging
Imaging is one of the fastest-changing technologies, and experts say there are still more advances ahead. "It's all going to be going down to the molecular level," Ronstrom says. "It's incredibly futuristic what's going to happen with imaging ... in five years we're going to see major, major changes," says David T. Feinberg, MD, CEO of the four-hospital University of California Los Angeles Hospital System. "Imaging has gone from being diagnostic to therapeutic. Interventional radiology is remarkably helpful in that you don't have to cut people open in the same way you did before."
UCLA was the first organization to offer clinical PET scan services to patients. Today, researchers there are studying the use of PET scans to detect Parkinson's disease, to visualize the success of different cancer treatments, and to determine the effectiveness of chemotherapy.
Minimally or noninvasive approaches such as the ones discussed can reduce complications, including postoperative infection, reduce length of stay, and lower the overall cost of care, studies have shown. They can also save money-an October 2009 study published in the journal Surgical Endoscopy found a difference of more than $15,000 on average for minimally invasive colectomies when compared to open surgery, for example.
What's Next: As minimally-invasive techniques are shown to be safer and more cost-effective, prepare for a wider variety of procedures to move to outpatient settings. And the more procedures a surgeon does outside of the hospital setting, the better the outcomes, including lower infection rates, Wenzel says.
Virtual medicine
Mayo Clinic researchers have been testing a supersensitive fiber-optic probe 2 millimeters in diameter that can be passed through a normal endoscope and can see structures as small as 1 micron, such as single cells or the nucleus within a cell. Probe-based confocal laser endomicroscopy, or pCLE, could eventually reduce colon polyp removal, and data suggest that the virtual biopsy can replace real biopsy in several other conditions, including Barrett's esophagus. The technology is "highly promising," says Michael B. Wallace MD, MPH, professor and vice chairman of medicine at the 214-licensed-bed Mayo Clinic in Jacksonville, FL. "We also have very promising data using confocal to assess the completeness of removal of very large polyps."
"We remain very optimistic that this technology will have an important role in guiding biopsy to areas that are much more likely to be disease, and in some cases, providing 'virtual biopsy' during procedures in real time so as to guide immediate therapy [instead of waiting several days for actual biopsies then repeating a procedure]," Wallace says. Dermatologist Babar K. Rao, MD, is particularly enthusiastic about a new device that uses laser imaging to help determine whether a lesion needs biopsy. The VivaScope, made by Rochester, NY-based Lucid, Inc., views skin abnormalities at the cellular level. "In many cases, it can save patients unwanted, unnecessary biopsies, and in some cases it may detect a lesion which otherwise might not have been biopsied."
In this case, virtual medicine is combined with wireless medicine. When a patient has a biopsy, he or she assumes the worst. The patient doesn't want to wait to hear whether he or she has cancer-not even a day. A telemedicine service can send the scope's images via a secure online network to pathologists for those providers who don't have one on staff or who want a second opinion, allowing physicians to deliver results faster than ever before.
What's Next: Don't invest in any device until you find the right person to use it. An inexperienced technician or diagnostician can do more harm than good. For example, when dermoscopy magnification was new, studies showed that when inexperienced people used it, the results were worse than when a physician did an examination with the naked eye, says Rao, who owns a private practice in Manhattan.
Artificial medicine
Heart, liver, lung, pancreas, bladder, ovary: Scientists continue to pursue advances in artificial organs. "We think that there are going to be a series of products that will become more and more sophisticated," says Aaron Kowalski, PhD, assistant vice president for glucose control research at the Juvenile Diabetes Research Foundation. He also leads JDRF's artificial pancreas project.
The artificial pancreas would help diabetics control their disease, as it reacts to changing glucose levels and delivers the right amount of insulin at the right time. It builds on two already-approved devices-the insulin pump and the continuous glucose monitor, or CGM. But unlike an open-loop system in which the patient is responsible for testing, reading data, and taking corrective action, the automatic closed-loop pancreas would use a control algorithm to read and interpret the information from the device and respond by dispensing insulin when needed.
The device would be particularly helpful at times when patients are most at risk, such as when they are sleeping and more likely to miss a CGM alarm. In such a case, the system would automatically intervene.
What's Next: Although the ultimate goal is to find a cure for any disease or condition, including diabetes, there are a number of near-term advances that will serve as bridges, Kowalski says. "These intermediary steps are important while we fight to get to the end of the disease-to a cure. When you're living with a condition, you want something now . . . even if it's not perfect."
Costs, benefits, and opportunities
Unlike in other industries, where advances in technology reduce costs (self-check-in kiosks at airports, for example), new devices and treatments typically drive up healthcare costs. A new PET scanner is a big investment, UCLA's Feinberg says. It also results in earlier diagnoses and more people getting treatment-and that drives up healthcare costs, as well. Someday colonoscopies will be performed by a pill you swallow, he says. But that means there will be more diagnoses of colon cancer, that those people will need further treatment, and that costs will go up.
On the other hand, says Sacred Heart's Ronstom, "Technology is going to be part of the answer for healthcare costs, because we're going to get quicker diagnosis, earlier intervention, and better safety."
"We had to justify [investing in the smart OR] in every way-not only to the hospital administrators, but to the board and the hospital owners as well," says Thapar. The benefit to patient care is obvious, but other benefits are demonstrable, too, from financial to quality of care to recruitment to marketing. "When you add it up from an accounting perspective," Ronstrom says, "we've done very well."
There's a fundamental question about the dollar value of preventing an error, an infection, a patient fall, or even a death, says Barry Rabner, president and CEO of the 477-licensed-bed Princeton (NJ) HealthCare System. "Every design solution that reduces or eliminates a problem has a cost, and finite resources make design decisions very challenging." You have to consider cost in the context of the benefit of improved outcomes and of the improvement in people's lives, UCLA's Feinberg says. "Our mission is to train the doctors of the future, to take care of patients, but also to discover tomorrow's cures. That's our core reason for existence . . . These firsts are what we exist for, and they have great societal benefit over the long term."
And then there's the business case: "We can't all afford to be early adopters," says Tom Hanenburg, CEO of the 168-licensed-bed Providence Medford (OR) Medical Center. "But if you're a lagging adopter, you're going out of business."
Technology, pharmacology, and clinical practice reimbursement all change meaningfully over time, and good hospital design requires careful consideration of those factors. Because predicting the future is so difficult, the chances are that you will make predictive errors, and, therefore, you must design as much flexibility into the building as possible, says Rabner, who is currently overseeing construction of a $447 million, 237-staffed-bed hospital to replace University Medical Center at Princeton, the system's aging acute care facility.
"One of our goals in developing the new building was to build in as much flexibility as possible," he says. The trick, he says, has been to put off final equipment decisions as long as possible, but not too long. "Technology continually evolves. All changes are not revolutionary but can have value. You do not want to decide too quickly and lose a useful feature or wait too long and have a building that can't easily accommodate the equipment you have selected," he says. Every healthcare leader will eventually make a misstep. Many have bought a piece of equipment touted as the latest and greatest must-have item only to see it end up sitting in a back hallway gathering dust, says Hanenburg. "The way to avoid that is to really have some trusted clinical advisors who are willing to also adopt the technology and use it once you buy it," he says. "Identify your core physician leadership-the ones that you trust to guide you well in terms of the technology you're looking at."
Hanenburg says there are several factors to consider when weighing an investment. The first is clinical impact: Will it improve outcomes? The second is whether your physicians want it: Will they adopt it? The third is a little tougher to ascertain: Will insurance companies pay for the procedure and, if not, how long will it take payers to catch up to any given medical advance?
Leaders must take it upon themselves to prepare to answer these and other questions, says Sacred Heart's Ronstrom. "We have to make a personal commitment to staying informed and staying knowledgeable on medical developments," he says. "We need to invest in our organizations so that the staff can stay current with their education, [and] we need to appoint clinical leaders who are really smart about clinical efficacy." Innovation is "the direction we need to go in this country," he says. "The answer for our economy is to make investments in technology, not just walk away from it. This is how this country was built-on our innovation and our discovery."
by Joe Carlson
Although the congressional prescription for healthcare reform will mean many changes for hospitals, the "real reform" that will transform how healthcare is delivered to patients still lies with the caregivers, American College of Healthcare Executives Chairman Christopher Van Gorder said.
"We know that once the political smoke clears, real reform will begin," Van Gorder said from the lectern Monday to open the annual weeklong ACHE Congress on Healthcare Leadership in Chicago. "After all these years, no one-and I mean no one-knows how to put healthcare reform into place better than us. ... Our role in healthcare reform is to make it real."
Sunday's 219-212 vote in the U.S. House to approve the Patient Protection and Affordable Care Act sent scores of ACHE speakers back to their laptop computers to draft new versions of speeches incorporating the very latest information.
"Yes, healthcare reform did pass last night so that you have more to talk about in between sessions at the largest gathering of healthcare executives in the world," ACHE President and CEO Thomas Dolan joked to a packed auditorium so large that it caused political analyst and commentator Stuart Rothenberg to observe that its participants might be seated in two different ZIP codes.
Rothenberg delivered the Parker B. Francis Distinguished Lecture on Monday, just hours after House Democrats passed their version of the healthcare reform law. No Republican voted for the House bill on Sunday, just as happened last December when the GOP uniformly voted against the Senate version of the same bill when it passed there.
Rothenberg, a longtime political handicapper who writes a column for Capitol Hill newspaper Roll Call and is editor and publisher of the Rothenberg Political Report, said the level of partisan divide was evident in the two parties' politically motivated statements after passage of the reform law.
"Let's face it, we're not going to know for many months, many years, how all of this will play out," Rothenberg said. "Right now, Republicans are trying to convince the world that the sky is falling, and Democrats say this is the best thing in the world. Don't believe either of them."
Rothenberg suggested that many Democrats may have supported the reform law-whose lengthy debate period he described as being "like pulling out teeth, without Novocain"-because they had to prove to voters that they didn't spend the past 18 months crafting a bill that couldn't pass. But in the long run, he predicted that the reform law will not change voters' widely held feeling that the country is headed in the wrong direction.
Although Democrats heading into their congressional midterm elections this year will emphasize the bill's positives, including those that will force insurers to cover more patients, overall voters seem likely to maintain their broadly negative image of the reform law. And that may be unfortunate for Democrats, as they're unlikely to take up any other significant legislative issues that would require more difficult votes that could further alienate independents before the elections.
"This healthcare bill is certainly the high-water mark of this Congress. Nothing else this significant will happen. The well is poisoned," he said.