HealthStream Inc

NASDAQ:HSTM

Earnings Call Analysis

Record Revenues and Uplifted EBITDA Guidance

The company celebrated a record quarter, achieving an all-time high in revenue and adjusted EBITDA. Revenue rose 5% to $70.3 million, operating income surged 104% to $4.9 million, and net income increased by 5% to $3.9 million. Earnings per share grew modestly from $0.12 to $0.13. Adjusted EBITDA marked a 28% rise reaching a record $16.2 million. Looking ahead, the company anticipates consolidated revenues to be between $277.5 million and $283 million, raised adjusted EBITDA guidance from $57.5-$60.5 million to $59-$62 million, and foresees capital expenditures of $27-$29 million.

Financial High Watermarks Achieved Amidst Growth Ambitions

The company has hit unprecedented levels of financial performance, setting new records with revenues peaking at $70.3 million, which indicates a 5% year-over-year increase. An even more impressive achievement is the operating income, which soared by 104%. The net income and earnings per share each rose by 5%, reaching $3.9 million and $0.13 per share, respectively. A significant highlight is the adjusted EBITDA that reached an all-time high of $16.2 million, up by 28%.

MyClinicalExchange and Nursing Education Partnerships

A prominently featured growth domain was myClinicalExchange, which expanded by 27% over the past year. This program aims to solidify the relationship with both hospital customers and future nursing professionals. Notably, a significant enterprise purchase was made by one of the country's largest nursing schools in the third quarter, opting for the American Red Cross Resuscitation Suite—an indication of the company's growing influence in the nursing education space.

Dividend Policy Signals Financial Strength

In a display of financial robustness and commitment to shareholder returns, the company has continued its quarterly dividend policy. A fourth installment was approved by the board and is expected to be paid out on December 22, with the 2023 policy projected to return approximately $3 million to shareholders. Such actions underscore the company's reliable performance and strategic intention to provide direct financial gains to its investors.

Product Suite Gross Margins and Competitive Landscape

Executive commentary suggested inherent higher gross margins over time within the growing sectors of the business. The CredentialStream suite, offering comprehensive capabilities connected to hStream technologies, has become a formidable player, demonstrated by a 56% year-over-year revenue growth and overwhelming competitiveness in the market, often becoming a finalist in related industry competitions.

Strategic Vision Towards a Platform-Centric Ecosystem

The company expressed a strategic move towards becoming a singular platform enterprise. By emphasizing a portfolio approach over product-specific metrics, the vision draws inspiration from leading tech companies like Apple, known for their unified ecosystem centered around user IDs. This methodology focuses on aggregating user engagement across over 50 product offerings that contribute significantly to revenue, aiming to enhance the value per user within the company's network, akin to Apple's use of single Apple IDs for ecosystem engagement.

Earnings Call Transcript 2023-Q3

[Operator]

Good morning, and welcome to HealthStream's Third Quarter 2023 Earnings Conference Call. At this time, I would like to inform you that this conference call is being recorded. [Operator Instructions]

I will now turn the conference over to Mollie Condra, Vice President of Investor Relations and Communications. Please go ahead, Ms. Condra.

[Mollie Condra, executive]

Thank you, and good morning, everybody. Thank you for joining us today to discuss our third quarter 2023 results. Also in the conference call with me today is Robert A. Frist, Jr. CEO and Chairman of HealthStream; and Scotty Roberts, CFO and Senior Vice President of Finance and Accounting.

I would also like to remind you that this conference call may contain forward-looking statements regarding future events and the future performance of HealthStream that involve risks and uncertainties that could cause the actual results to differ materially from those projected in the forward-looking statements. Information concerning these risks and other factors that could cause the results to differ materially from those forward-looking statements are contained in the company's filings with the SEC, including Forms 10-K, 10-Q and our earnings release. Additionally, we may reference measures such as adjusted EBITDA, which is a non-GAAP financial measure. A table providing supplemental information on adjusted EBITDA and reconciling to net income attributable to HealthStream is included in the earnings release that we issued yesterday and may refer to in this call.

So with that start, I'll now turn the call over to CEO, Bobby Frist.

[Robert Frist, executive]

Thank you, Mollie. Good morning, everyone. We have a lot to cover for our third quarter 2023 earnings call. In the third quarter, we achieved record revenue and record adjusted EBITDA. Top line revenue reached $70.3 million in the quarter, which was up 5% over the same period of 2022 and adjusted EBITDA increased to $16.2 million, which is a 28% improvement over the same period of 2022. If I reflect back, it was a quarter of financial high watermarks, also excellent progress on our single platform strategy, some exciting sales wins I'm going to talk about. But most of all, the quarter was characterized by the strong leveraged EBITDA growth we delivered and expect to continue delivering.

Another way to think about performance is through the higher margins and greater operating efficiency we delivered. For example, through our investments in proprietary content and applications, our gross margins have improved to be in line with our medium-term financial goals of 65% to 68%. In addition, our single platform approach continues to streamline how we organize our workforce.

For example, we delivered increasing revenue per employee for the past 4 consecutive quarters. Let's take a minute just to kind of refresh and really define HealthStream for our audience. I think we might have some new folks out there that want to hear how we describe and position our business.

First and foremost, HealthStream is a health care technology company dedicated to developing, credentialing and scheduling the health care workforce through SaaS-based applications and solutions, each of which are becoming more valuable because of the interoperability they are achieving through our hStream technology platform. We sell our solutions on a subscription basis under contracts, which average 3 to 5 years in length. That means our revenues are recurring and predictable. In fact, and we checked this the course yesterday, 96% of our revenues are subscription-based.

We are profitable. We have no interest-bearing debt. We have a strong cash balance of $71 million and we are solely focused on health care and more specifically the health care workforce. In fact, the way we define our addressable market is as the 11.2 million health care professionals working in the United States in health care organizations. Though our market is also beginning to show signs of expansion into the pre-professional markets like nursing schools as well, and we're going to talk about that in the second half of this presentation this morning.

As we enter the fourth quarter, we are confident that HealthStream will continue to provide results in line with our guidance range, importantly, including our increased guidance range for adjusted EBITDA of $59 million to $62 million. In addition to expanding into new markets like nursing schools, this quarter, we demonstrated some increasing share of wallet with existing customers. And I'm really excited to highlight 2 examples of that in the quarter.

First, one of our large customers renewed their HealthStream Learning Center and their hStream subscriptions for learning for 16,000 users, but they didn't stop there. They also decided to leverage our marketplace of workforce solutions and they added EBSCO clinical skills, our checklist product, Psych Hub, Skillsoft, HealthEquity and Belonging curriculum, and Talent Tracks, one of our development programs as part of their 5-year subscription. That 6 new products add at the time of renewal. And as a result, this account is moving from approximately $16.52 per person per year to $30.99 per person per year. And this was not an isolated example.

Another one of our large accounts expanded their HealthStream Learning Center contract and their hStream subscriptions for learning from 15,000 to 19,000. But while they're expanding the subscriptions, they also were renewing their SafetyQ product, their checklist and their CE Unlimited orders. They also added new to the contract, our Quality OB program and our Jane products while additionally expanding their subscriptions to our nurse residency program. So for all for a 3-year term, so for this account, we're moving from approximately $81.24 per person per year to $108.58 per person per year.

And remember, the count went up from 15,000 to 19,000 all in the same renewal process. So we're excited to be demonstrating this expansion of wallet share at the customers that we already have. And obviously, these 2 examples are customers that are deep into our ecology. They kind of shop within the 4 walls of HealthStream Ecology. Our partners and programs are promoted to them in our various applications that are increasingly interoperable become more interesting to them. So these are 2 great examples.

We have a strategic accounts program. The goal is to expand like this at our top 150 accounts. So we're really excited to see these 2 great renewals, extensions and product additions, increasing share of wallet. So we're grateful for the significantly expanding commitments to these customers and others like them that they're making each time they come for renewal. And we want them to know that HealthStream is committed to ensuring they get even greater leverage out of their hStream membership. That's that underlying infrastructure that's making it all work together. And each time the renewal rolls around, trying to make sure they appreciate the interoperability that every quarter we release new capabilities that show interoperability of our various application suites.

It's also a strong quarter for our CredentialStream solutions, and this is important because we put a lot of capital into building out our CredentialStream solutions in the credential privilege in enroll area of our company. And so it's great to see that we're finally seeing and beginning to see really strong growth. So both in terms of competitive takeouts and conversions from our legacy solutions, in the third quarter, we contracted 32 new customers for our CredentialStream solutions. And that, importantly, represents about 114,000 new subscriptions collectively. And remember, when you subscribe to our CredentialStream application suite, you also become a member of our hStream for credentialing and hStream platform technology. So we're excited to add through part of the model, 114,000 new subscriptions.

New customers include highly respected health organizations like Northwell Health, AlohaCare and Banner Health. And revenues from subscriptions to CredentialStream in the third quarter grew 56% over the same period last year. Not the smaller product. It's still in our top 10 for sure, but we're really excited to see this application suite that we've been consistently investing in for several years now show this exciting growth. Again, with 32 new takeout or new customers and 56% year-over-year revenue growth.

But not to be outdone, we have another area of our business that's performing. It's our -- in the third quarter, revenues from ShiftWizard, which is our scheduling business grew 33% over the prior year quarter as customers continue to report high customer satisfaction. So really excited to see this relatively modest, as you all know, we acquired 3 companies in the scheduling space, and we're beginning to see some real promise in growth in this area, even though we have a lot of building to do in this area of increased investment as well. But we're really excited to deliver 33% year-over-year growth in the ShiftWizard subscriptions.

We have selected ShiftWizard as our primary kind of go-forward application set, and we're significantly expanding its ability to perform at an enterprise scale. And so we're working to make our ShiftWizard application appropriate for our largest customers, and we continue to invest to add scale and capacity and new features and capabilities to the ShiftWizard application suite. Really excited for the teams delivering that. And during the quarter, some of the many new customers that we added were Palomar Health, Great Plains Health and Richmond University Medical Center. So excited to see some great new additions to our customers coming and joining the HealthStream ecosystem by selecting ShiftWizard, the application suite.

So obviously, really exciting developments during the quarter. And we just -- in the back half of this, after I turn it over to Scotty, we're going to talk about -- we talked about kind of share of wallet in the first half year. We'll talk about market expansion opportunities in the second half. So let's turn it over to Scotty and do a deep dive in the numbers and bring it back to me for reduction of market expansion.

[Scott Roberts, executive]

All right. Thank you, Bobby, and good morning. I'll jump right in and hit the financial highlights for the third quarter. And unless otherwise noted, the comparisons will be against the same period of last year.

As Bobby mentioned, it was a record quarter in which we achieved new high watermarks for revenue and adjusted EBITDA. We achieved record revenues of $70.3 million, up 5%. Operating income was $4.9 million, up 104%. Net income was $3.9 million, up 5%. Earnings per share was $0.13 per share, up from $0.12 per share. And finally, adjusted EBITDA was also a record high, coming in at $16.2 million and was up 28%.

Now let's start with revenues, which surpassed the $70 million-mark for the first time and were up $3.1 million or approximately 5% compared to last year's third quarter. Revenues from subscription products accounted for 96% of total revenues and our subscription revenue came in at $67.5 million or an increase of 5%, while revenues from professional services were $2.9 million and declined by 11%. As a software company, our focus is growing subscription revenue versus services revenue and the quarter's performance reflects just that.

Gross margin was 66.5%, up from 65.3% last year and positively benefited from changes in revenue mix, including growth from products that we own. Additionally, cost of revenues only increased by $0.2 million or 1%, which was due in part to lower compensation expenses resulting from the organizational changes that we implemented earlier in the year. Though these were partially offset by our hosting and software costs.

Operating expenses, excluding cost of revenues were up $0.4 million or 1% over last year's third quarter. Depreciation and amortization were up 8% and G&A was up 2%, while product development and sales and marketing were down 5% and 1%, respectively. Our product development costs declined by 5%, which is net of labor costs that were capitalized for software development. We maintain a consistent level of staffing and base compensation compared to last year, our capitalized labor costs increased approximately $600,000 over the prior year quarter.

Sales and marketing expenses were down 1% or less than $100,000. Staffing levels were down slightly, resulting in lower base compensation, but this was partially offset by higher sales commissions, which is consistent with the growth in revenues. G&A expenses increased by 2% or around $200,000 and were mostly a result of higher bad debt charges and professional service fees but were also partially offset by lower staffing costs and other general expenses.

Our adjusted EBITDA was a record high of $16.2 million, which was up 28% and our adjusted EBITDA margin improved to 23.1% compared to 18.9% last year. The growth in revenues, improved gross margins and their operational efficiencies from the consolidation efforts we made during the first quarter led to this improvement.

Now let me mention our hStream subscription count before moving on to the balance sheet. In the third quarter, hStream subscriptions increased by $113,000 over the previous quarter, total of approximately $5.7 million.

Now let's take a look at the balance sheet metrics. We ended the quarter with cash and investment balances of $71.8 million, which was up from $56 million last quarter. During the quarter, we deployed $6.7 million for capital expenditures, paid $0.8 million to shareholders through our dividend program, and we repurchased $2.1 million of our common stock under the share repurchase program that we announced in September.

Day sales outstanding increased to 43 days compared to a record low of 38 days last year. But DSO came down by 7 days when compared to last quarter. As a matter of context, I'm comfortable with our receivables metrics and the improvement that we made during the quarter with cash collections.

On a year-to-date basis, our cash flows from operations improved by $7.1 million or 16% versus last year, coming in at $50.2 million and free cash flows also improved to $28.8 million compared to $24.1 million last year. As for the third quarter, free cash flows were $18 million, another record high for us, which help boost the cash balance to over $71 million. Remember, our free cash flows are seasonal with the first and third quarters generally being the strongest and cash flows tending to be closer to breakeven in the second and fourth quarters.

With regard to our capital allocation, aside from the capital investments that we make into our products, we're also deploying capital to improve shareholder value through cash dividends and share repurchases. Since the adoption of a dividend policy by our Board of Directors earlier this year, we have made 3 quarterly cash dividend payments so far this year, returning $2.3 million back to shareholders. And yesterday, our Board of Directors declared a fourth quarter dividend that will be paid in December.

In respect to share repurchases, last month, we announced a $10 million share repurchase program. We made $2.1 million of share repurchases during the third quarter and through yesterday, we had purchased a total of $8.9 million under the $10 million program. And this program will terminate on the earlier of March 31, 2024, or when the maximum dollar amount under the program has been extended. We may suspend or discontinue making purchases under the program at any time.

Also, earlier this month, we entered into an agreement with Truist Bank to renew our line of credit facility for another 3 years. The credit facility terms and conditions are basically the same as before, and you can find out more details about this transaction in the Form 8-K we filed on October 10. You'll notice that we capped the facility at $50 million, which we feel is an appropriate size for us given our strong balance sheet and growing free cash flows.

Now as for guidance expectations, we have updated our financial expectations as follows. We continue to expect that consolidated revenues will range between $277.5 million and $283 million. We have updated adjusted EBITDA, which is now expected to range between $59 million and $62 million compared to the previous range of $57.5 million to $60.5 million. Capital expenditures are still expected to range between $27 million and $29 million. While our guidance includes the acquisition of eeds, which occurred late last year, does not include assumptions for any acquisitions that we may complete during the remainder of the year.

So now let me take a brief moment to provide some additional thoughts on the guidance before turning the call back over to Bobby. Our forecasted revenues for the year are trending to around the midpoint of the range, which would imply around a 5% growth rate over the last year. And as for adjusted EBITDA, our focus on operating efficiency and higher gross margins is translating into financial leverage. And at the midpoint of our increased guidance range, this would imply around 13% growth over last year. Furthermore, I want to share 2 other metrics that reinforce our performance.

Our annualized revenue per employee has improved from $234,000 to $259,000 and annualized adjusted EBITDA per employee has improved from $44,000 to $60,000 compared to the third quarter of last year. That concludes my comments for this quarter's call. Thanks for your time this morning, and I'll now turn the call back over to Bobby for some additional updates.

[Robert Frist, executive]

Thank you, Scotty, and excited to dive into that portion of my presentation here. In the first half of the call, we focused on how we're selling more products to existing customers. And now I want to take this portion and focus on some market expansion that we're working on and very excited to see some traction in.

So by selling directly to nursing students and nursing schools, we're just beginning to sell our products to a whole new set of customers, and we saw some traction on that in the third quarter. Some of you may recall that we acquired a company called myClinicalExchange in December of 2020. And you can think of myClinicalExchange, both the company and the product as a bridge between students, these nursing students, and the hospitals that hire them and put them into rotations to gain experience to ultimately become a nurse. So myClinicalExchange is like a connection bridge between the student and those rotations. And it's also used interestingly to kind of credential and profile and onboard these nurses into these internships and rotations. So it has a little dimension to it to kind of qualifying the applicants as well.

Year-to-date, we generated just over $3 million of revenue from this product, again, kind of a new category for us. And that's a 27% increase over the same period last year. So it's exciting after we deploy the capital and the acquisition and kind of declared that we'll be entering the market of these students. We just love this idea because they get to the students, even pre-profession before they're nurses. And then they enter the workforce with hStream ID, and we're just really excited to see progress in those areas.

So far this year, we placed over 161,000 clinical rotations. So that's placing a student of some sort, most nurses, into a rotation in a hospital. And the hospitals love this because, of course, as they become nurses, they become candidates to work at that hospital. So this product, myClinicalExchange, which grew 27% over the prior year, is doing 2 great things for us, helping us be an ally to our hospital customers by bringing them the best nursing students. And it's also allowing us to build a business relationship with these nursing students before they enter the market as professionals, so they're engaging with our technologies and platforms earlier in their career, which we're really excited about.

So when they enter into the myClinicalExchange application, it gives HealthStream direct access to the students who use it. And with this access, we can better understand what products the students need before they transition into their professional careers. And we can begin selling those products directly to them and importantly, to their schools.

So in addition to targeting the expansion by targeting the nursing students, we're also expanding to selling to nursing schools. In the third quarter, 1 of the largest nursing schools in the country, completed an enterprise purchase of the American Red Cross Resuscitation Suite. And we're really excited to see this dynamic because how exciting is it for a new nurse while in school to earn this credential and carry it forward into the market. So after careful consideration, this customer determined that HealthStream and the American Red Cross provide the best solution for fulfilling the resuscitation certification need of student, and it's a 2-year credential.

So they enter the market now with that credential. And if they show up at a hospital that uses the hStream platform and those credentials automatically populate into the learning application. So again, another example of interoperability finding new -- in this case, customers or individual professionals before they [indiscernible] would have engaged with HealthStream.

For us to be engaging earlier, we're excited for these graduates to enter the market with this stronger resume. We're excited for the Red Cross who gets to develop the clinical skills of these at an earlier stage than they might have otherwise. So all around, a lot of excitement about how we're expanding the definition of our market to include the pre-professional market and specifically nursing schools.

So we're in the early days of this journey, but you can tell from myClinicalExchange traction, the 27% growth and that we're getting to this new market and they're entering the market with their hStream ID, which is just a really exciting new way to think about how we define our market overall. So I'll shift gears here and just wrap up for our employees by showing how we're demonstrating our streaming good value. We have this constitution, we run our business by and streaming is one of our many important values. And we're able to demonstrate a streaming good value in this quarter.

By the way, we were able to serve the health care professionals on the front line in Maui, where the historic fires were really devastating overall. And they include just kind of incredible mental health challenges for the workforce as they tried their best to provide services and care for the survivors of those horrible fires in Hawaii. So HealthStream was able to team up with 1 of our partners, Psych Hub, an we were able to -- which we do have an equity investment in Psych Hub, so that was exciting for that reason as well. And we also teamed up with Hawaii State Nursing Center -- the Hawaii State Center for Nursing and we organized a complete online offering of psychological first aid training and education, and we did this free of charge.

And so we're able to help Hawaii, help the nursing -- the nurses in that state, in their recovery mode and kind of process all of they are going through. We're excited that allow our employees to live their streaming good value and provide this valuable service at a time of need. And just for idea of how we can extend our capabilities to our platforms and technologies for the betterment in this case, the well-being of the nurse population and the health care providers that we're fighting so hard on the front lines in Hawaii. So we're honored to be a crucial resource to these health care professionals and that we consider them national heroes, and we're excited to be a part of that provision of care.

So as we close this portion of the call, I want to -- I do want to remind you about our dividend policy, we began earlier this year. We made the third payment under this policy about a month ago. And just yesterday, our Board approved what will be the fourth installment of quarterly payments under the plan, and that will be paid on December 22. We're pleased with our strong balance sheet and our strong operational performance puts us in a position to return value directly to shareholders as the company's first quarterly cash dividend program.

Over the course of full year 2023, we expect our new dividend policy to return approximately $3 million to shareholders. And we're on track to meet that goal, and we will consider whether to expand dividend program next year. So we look forward to taking that up in future board discussions. If you're interested in a profitable recurring revenue, 96% subscription SaaS pass health care technology company that for 2023, expect to deliver steady growth and is determined to share some of those gains directly to shareholders, maybe HealthStream is the company and the stock for you if you're here listening. We'd love to have you guys as shareholders to go on this journey with us.

Let's turn it back over to the operator and begin the Q&A session with our analysts.

[Operator]

[Operator Instructions] Our first question comes from the line of Matt Hewitt with Craig-Hallum.

[Matthew Hewitt, analyst]

Thank you for all the detailed commentary so far. Maybe first off, what are you hearing from hospitals, just the broader market trends? Obviously, you had a couple of companies report this morning. talking about procedure volumes up, but still seeing some difficulties or headwinds on the income side of the equation. What are you hearing from customers? And how are you able to kind of navigate that?

[Robert Frist, executive]

Well, the challenge for them is a lot of their issues around workforce. We do think that our solutions are a great aid in the development, retention and better management of the workforce. So part of that cost structure that they're working hard to manage is related to workforce retention, engagement and development. So I think we're aligned with helping them do the challenges that may be driving some of those financial challenges that they articulated. So I feel aligned with our customers and trying to help them through this period. It's good to see the volumes up. We like that as a sign of strength for our hospital customers and all of our continuum market customers as well. So there's some signs there that are positive. And I do think the areas they have the biggest challenges and are the topics of the CEOs, which are how do we retain, engage, develop and better manage our workforce.

So we're proud that our 1,100 employees are aligned. And when we're called in, we can be a help on everything from a psychological well-being, like we talked about in Hawaii, to the skills development like the Red Cross program which we think is a lower cost, higher quality program than the competition and all the way on through to nursing skill development with our Jane products. So we think that we're aligned to help them work their way through the challenges that they are talking about in the macro level.

[Matthew Hewitt, analyst]

Understood. That's helpful. And then a question, that the 11.2 million employees that you -- that your applications address. Does that include the nursing schools, the students, that you are now kind of opening up this new market?

[Robert Frist, executive]

I don't think it does. I'm about 98% sure it does not. We -- that metric is defined in our Ks and Qs, and I'm pretty sure it doesn't include the pre-professional market. And so nursing schools, we are believing and on this call, declaring as an expansion of our opportunities. So we may have to adjust that number over time. It's new for us and our first big sale occurred in the quarter. So we'll look to see how to adjust that definition of market. But we are particularly interested in getting to these right before they become nurses. We don't go all the way down to grade school, but I do think catching them in their last year of nursing school, we're clearly now onboarding tens of thousands of new nursing students into our network and getting them an ID right before they enter the professional market. And so we're really excited about that. I think that represents a market expansion and definition for us.

[Matthew Hewitt, analyst]

That makes a ton of sense going after that, those potential future nurses. And so maybe one last question, maybe more for Scotty, but gross margins, obviously, another nice step up there. And I know it's within the midpoint of your kind of your 3-year target. But what would be the impediment of kind of growing beyond the 67%, 68% over the near term? I mean, is there anything that would stand in the way of that? I mean you've seen some pretty nice growth in that metric over the past few quarters. I'm just curious what would be the -- what would prevent you from expanding further?

[Robert Frist, executive]

I'll try first and let Scotty add. I think one of the things that we're excited about is that almost all of our new products are being built using our platform technologies, use some of our APIs that gives us a little inherently more leveraged and a little faster rate of production of new products and introduction of those products. So my general sense is that the ideas in the pipeline and the things that we're working on are generally either data-driven products where we own the data, our content products, where we own the content or application suites that we're building organically using our new platform technology.

So in general, over time, I think that the growing parts of our business have inherently higher gross margins. So right now, we need to stay and define our target within that range. But I think there should be this kind of continued slight upward pressure on that gross margin opportunity because the nature of what we're building is different than, say, the origins of the company that were built around partner content that had higher cost of goods. So I think that my general answer is that I don't see what could stop us from continued expansion. But we have outlined these 3-year objectives, and we're really excited to be landing already on that 1 measure in the range of our multi-year objective. So we're glad to see that progress year-to-date.

Scotty, If you want to add anything to that, but hopefully, that addresses the question.

[Scott Roberts, executive]

Yes. I mean I think, Matt, that's obviously where we're headed is. Trying to continue to improve on that metric. And just for a little additional context, just one thing to keep in mind as we've talked about transitioning to a PaaS company and continuing to progress down that road. One of the things that's influencing margins to some degree likely continue to influence margins is just a move from a traditional hosting environments on a co-location type of environment to cloud hosting. So our investments in cloud continue to increase. And obviously, that's the cost of delivering our service. So it's influencing margins to some degree. But as our products continue to migrate towards higher-margin solutions. We think that will overcome some of those costs that we're seeing increasing related to cloud.

[Operator]

Our next question comes from the line of Jared Haase of William Blair.

[Jared Haase, analyst]

Yes. This is Jared Haase on for Ryan Daniels. Bobby, maybe just -- was hoping to get a little bit more color on the credentialing application suite. And specifically, I know you announced a couple of new product innovations for that suite of products. So it would just be great to get your perspective of how you're thinking about the demand environment for the CredentialStream suite and maybe how you're still thinking about HealthStream position relative to the market?

[Robert Frist, executive]

Sure. On the CredentialStream suite, it is -- first, you got that right. It is a suite. And so it's a set of roles and capabilities and application that is increasingly connected to the hStream technologies. It has some really powerful differentiators built into it, like our privileged library, which is a curated data asset that we own and a differentiator in the market. So -- and it's also, we believe, 1 of the most complete application suites in the market. So we think it's highly competitive against the competitive landscape. We find ourselves a finalist in almost every competition that is available to us in the markets that we've defined.

And so we think it's competitive because it includes capabilities around credentialing, privileging, enrolling them insurance and insurance and the onboarding process is both facilitating some of the HR onboarding processes like training and facilitating the EHR provisioning process by also delivering some of the training to get them ready to be provisioned on the electronic health record system. And so we think we just have a very complete definition of the application suite that works together really, really well.

Also, one of our philosophical differences in our competition is it's kind of a physician centered process, kind of a back-office process. Our Physician Hub is gaining in both popularity. We watch it's Net Promoter Score, which is positive. And with physicians who are taking a little bit more personal control over this credentialing, privileging, enrollment process. So the physician hub component is also, we think, a differentiating point of view for us redefining the workflows a little bit around the Physician. And we're seeing that engagement really be strong with the physician hub component of the CredentialStream application suite.

So overall, we think we are well positioned as demonstrated by adding a 32-plus customers across that suite during the quarter. And also, we're -- it's nice to see the subscription revenue starting to compound a little bit. And I think the number was 56%. Let me look back at my note. Maybe Scotty, what was the revenue growth rate year-over-year on CredentialStream?

[Scott Roberts, executive]

I think you got it right, Bobby.

[Robert Frist, executive]

Yes. I think it's 56% and ShiftWizard was 30-something percent. So Yes. I think overall, I hope that answers the question. We feel it's very competitive, a finalist in every deal we look at, and we believe we win more than we lose. So really excited about how well positioned that application suite is. We acquired several companies over a decade and rebuilt the core application set, and we have over 700 agreements on that core new application set and expanding, obviously, rapidly. So we're excited.

[Jared Haase, analyst]

Okay. Great. And then just as a follow-up, I wanted to talk about staffing. It sounded like you mentioned labor costs were down a bit year-over-year. Can you just remind us where you're at kind of relative to your broader hiring needs? I think last quarter, you talked about having a handful of open positions that you're expecting to fill during the second half of the year. So maybe just a quick update of where we're at and how we should sort of think about kind of a run rate for operating expenses going into 2024?

[Robert Frist, executive]

Yes. I think we have about 50 open positions. I think we're recruiting for about 20 of them. We have some new hiring models which are exciting where we hire kind of cohorts together and bring them in as a team on. For example, we just hired a development cohort for one of our applications, the ShiftWizard application, which allowed us to move the development of that from an offshore team to a HealthStream team. So we do have open positions and with the natural turn. We're also using departure as an opportunity to reshape the business.

And so we've got all of our managers thinking about that if people do elect to leave, we're using that opportunity to think about our structure and where our emphasis is. We're trying to put more emphasis on the customer and connectivity and on development. And so those are 2 areas of relative investment. Overall, I'd say our employment numbers are fairly stable with the kind of puts and calls of natural turn performance-based terming and also the hiring that's going on. So I think overall, around this 1,100 number is a good way to think about the scale of our workforce in the coming quarters.

[Operator]

Our next question comes from the line of Richard Close of Canaccord.

[Richard Close, analyst]

Great. Can you hear me okay?

[Robert Frist, executive]

Yes, Richard.

[Richard Close, analyst]

Okay. Excellent. Well, first of all, congratulations on the success here. A great quarter. I was just curious on -- you just mentioned the CredentialStream and revenues grew 56% in the quarter. ShiftWizard, I believe you said 33% over the prior quarter. And then just looking at those growth numbers your revenue growth overall was like 5%. So just curious there, is some of the growth in CredentialStream and ShiftWizard that you referenced, is that some cannibalization of the legacy products? I just thought with those numbers, total would be greater.

[Robert Frist, executive]

Yes, yes. So there's definitely some of that. As we know, we acquired a lot of applications and some of those we classify as legacy applications. And our goal is to move those customers. So that is true. Some of that comes from migration as we talked about. And some of it comes from new wins out in the market. And it's probably around for credential anyway around 50-50, I believe, maybe I'm a little off on that. But just historically, I think in any given quarter, is a little bit of I guess you would call it cannibalization, but we call them successful migrations to a SaaS subscription application suite.

So -- but some of that growth number is the migration from the legacy applications over. And again, we celebrate those migrations. And there are definitely new business on the newer applications. And we think on CredentialStream, it's probably about half. And I'll see if anybody texts me one of my officers anything different than that. But I'm going to say ballpark the last few quarters is probably around half.

[Richard Close, analyst]

Okay. So the lower growth rate overall for total revenue doesn't it imply like customer churn, the learning platform or anything significant like that?

[Robert Frist, executive]

Well, there's always a little of that. We've got a lot of market share. And so there's always a little come and going. I think what we're trying to highlight most recently, though, is where -- once we get a customer in for 3 or 4 of our products, they seem more likely to go from 3 or 4 to 8 to 10 than they do to leave. Now when we have just 1 product, we got a toe in the door a few years ago and maybe they change -- they make the difference in business decision on that product, that's where we lose them on that product, and we also lose them on the hStream platform.

And so I think a couple of quarters ago, that happened on a few accounts. We don't consider them like real ecosystem partners. And so we're really excited this quarter to see the change in a couple of our key big renewals. This quarter went the other way. And so we're really excited to watch them go from 5 products to 11 products and doubling their subscriber revenue per person per year. And obviously, that's more typical because overall, we have growth, and we have growth in our newer product categories.

[Richard Close, analyst]

I know you're probably not going to want to answer this question, but is there any way to sort of size as a percentage of overall revenues like the Learning versus Credential and ShiftWizard in terms of...

[Robert Frist, executive]

Well, I think you are right because we're really -- what we're trying to get, Richard, and we're just not there. We have this -- I'll call it a very immature metric, this hStream subscription. In fact, we're still -- a lot of work to do to clarify differences in subscriber and a subscription to -- we've broken down this platform hStream into hStream for learning. Almost think of it as a membership in our learning network, hStream for credentialing and hStream for scheduling. So we've created these value bundles that are kind of infrastructure that are bundled with the sale of each core application.

And what we're trying to get, obviously, is to sort out how many unique individual professionals are in our entire network. And I think our goal is to get to a place where we can say that, Bobby the nurse on credentialing, is the same Bobby the nurse on NurseGrid, is the same Bobby, the nurse on our learning application, and they spend 3 hours here and 1 hour here and 10 minutes there each week. And this hStream ID technology that we're rolling out now will help us reconcile all that. And we'll get to a better numerator-denominator around the subscriber number versus the subscriptions sold to these kind of application suites and their supporting infrastructure.

So that's a long way of saying we're trying to move to a single platform metric kind of goal where we can get to this revenue per person per year. And then we may or may not break it down by categories like learning and scheduling, but you can see our extreme focus on at the account level to grow the revenue per person per year. And -- we're just not quite there yet.

The metric itself isn't mature enough and it's not wired to all of our applications, so it can't be used yet like a cable company would, where you can say revenue per person per year company-wide per product category. But that's where we're headed. And we've launched new scorecards internally so our product managers can start to know like, "Well, my product adds $2 per person per year to the overall metric. And so my hope is the next year or so, we can refine these metrics further. So they'll be a little bit more correlated to the growth trajectory. We'll get them connected technologically to more of the application so that all applications are contributing to the denominator of that measure, adding hStream subscribers. And also, we've got a team of people working hard to reconcile the unique subscribers.

So that we know that Bobby on hStream for learning is the same Bobby on hStream for scheduling. So that's a long way of saying, you're right. We don't want to be segmented into these 3 application suites. Instead, we want to be thought of a single platform, almost the way you think Apple issues 1 billion Apple IDs, and that's the way they think of 1 billion users of their ecosystem, and then they start to think about where they're getting them to invest and spend money across that ecosystem.

So we're trying to be a single platform company and we're working hard at structuring our application suites and our infrastructure to support that form of metric instead of breaking out per product. Because we have so many products in the eco of the system that it makes a little less sense, maybe the product managers in my company, they all know that I have 300,000 subscribers at $2 per year on my product, but we already have over 50 products that generate $1 million a year. And so we're thinking much more portfolio-like and then aggregating it around the users, and that's where we want to get with the hStream metric someday. But right now, it's a little bit of a disconnected metric. We've been reporting it for a while. Definitely better up and down. But in the coming quarters and years, it's going to be much more meaningful.

[Richard Close, analyst]

Okay. That's very helpful. And then Scotty, I was going to ask with the subscription model, I thought the guidance range for revenue seemed a little bit wide, but just wanted to go back in terms of your added commentary. So you're expecting to be roughly at the trending towards the midpoint of the revenue range?

[Scott Roberts, executive]

Yes. Richard, that's where we are forecasting. That's the remarks that I made.

[Richard Close, analyst]

Okay. I just wanted to clarify that. That's really helpful. And then, Scotty, maybe on the product expenses, I was curious, it declined sequentially. Was there -- if I go back to last quarter, I thought you said you're going to continue to invest and whatnot. But I was just curious if there was anything specific from, call it, second quarter to third quarter that led to that sequential step down I'm not mistaken?

[Scott Roberts, executive]

Yes. No. I think relative to last year, it was down. I have to go check my numbers on sequential. But I think in my remarks, just pointing out that capitalized software development continues to increase for us. We're obviously putting more emphasis on product development and just the mix of projects that are ongoing and how that translated into what was capital versus expense implants year-over-year. I'll go back and look at sequential activity. But I think -- as we mentioned, as Bobby mentioned just a few moments ago about staffing and it was fairly flat in the quarter.

And so from a cost perspective, a lot of movement in the cost structure. And as Bobby also mentioned, as we have departures, we're looking strategically at how to reinvest those freed up dollars to put back into the company may not be an equal trade-off on 1 position leaving and no one coming in. So we're being more strategic about how we deploy those funds back into the business as well.

[Richard Close, analyst]

Okay. I guess my final question is, I thought it was interesting on the $3 million of revenue year-to-date. I believe that's myClinicalExchange. And Bobby, can you just remind me like who's paying you guys that $3 million? Is that the nursing schools or the nursing students themselves?

[Robert Frist, executive]

Yes, yes, that's great question. It's a really fascinating model, we're excited about it. Here's how it works. The software -- the hospital gets some software as part of the solution set. It allows them to pick through the students and choose who get a rotation and also take their preliminary application in for the rotation. So the hospital has some software. The nursing school did some software. So they can see the profile of their students that they're pushing forward into the hospital network. And the student also has software access.

They get access to build their profile, essentially a little bit like LinkedIn, so they can kind of profile themselves. And the model is set up so that along that chain, almost anyone can choose to pay for it. And so it's about -- I believe it's about $30 per person per applicant essentially. And about half of the market lets the student pay. And so when the student enters their credit card and they pay the $29, they get access to this network and that helps them find a rotation.

In some cases, about the other half, I'd say, the hospitals choose to pay as part of almost recruiting future talent. And so it's about 50-50 of the $3 million, I believe, half paid by hospitals and half paid by the student. And in some cases, they make it kind of part of the program at the nursing school. So it would be almost like the school pays and gets reimbursed. But the easiest way to think about it, about 50% is paid self-paid by the student and about 50% by the hospital. And the hospitals are largely the ones that decide which model to adopt. They can say, push the application fee out to the applicant or they can choose to pay for, for their network.

[Richard Close, analyst]

And then is there any tie-in to like myClinicalExchange and the nursing app that -- what was it nurse...

[Robert Frist, executive]

NurseGrid.

[Richard Close, analyst]

Is there -- is there any integration between these 2 things?

[Robert Frist, executive]

Not yet, but we have concepts that they might apply for their nurse -- myClinicalExchange through the NurseGrid app. We have concepts that we're working on that would allow -- well, as you know, I think you know we're working on offering learning to the NurseGrid network and offering learning to the myClinicalExchange network. So our new platform gives us commerce capabilities now that we didn't have before. That allows us to make products available in both of those networks. And of course, my vision would be to have those work together. I know the teams are working on lots of ideas to make them more interoperable, but right now, we essentially are going to infuse commerce into both of those channels by year-end, in fact. So we're excited that those will become opportunities in the next really 60 days.

[Operator]

Our next question comes from the line of Vincent Colicchio of Barrington Research.

[Vincent Colicchio, analyst]

Yes. You had a very healthy growth in average revenue per employee, nice to see. I'm wondering if you have a growth. A comparable data point for the renewals maybe that would provide some sort of anecdotal indicator as to where the overall metric may be headed?

[Robert Frist, executive]

Oh, great, you mean at the account level? So we did give 2 examples. Obviously, they are really good examples and -- but they are larger. And so it's great to see 1 account almost double from $16 to $30-plus per person and the other go from, I think, is around $80 to $108.So -- but we don't have that metric wide. Of course, we have about 60 people in account management that manage our top hundreds of accounts, and their goal is to grow revenue per subscriber. And of course, my goal, as I've mentioned in the coming quarters and years to get to a place where we can share those numbers globally where averages will start to mean things across our hStream for learning subscription, hStream Credentialing and hStream scheduling, which should launch this quarter.

So I don't have an answer for you now. We have a couple of exciting examples, and it's directionally where we're going, Vince. And we have teams of people, account management, in particular, focused on growing the revenue per person per year. But right now, we can kind of only cite samples instead of reporting kind of averages across the product set. But we'll get there. I think that you've hit the nail on the head about where we're trying to get, so it would be even much easier for you guys to model our growth. So you're on the right track, you're a little in front of us. I need a few more quarters.

[Vincent Colicchio, analyst]

And then the identity management and license management products on the hStream platform, are they meeting expectations?

[Robert Frist, executive]

Really exciting. We've taken that license verification service, which is a data-driven service. We've bundled it in with your hStream for learning subscription. So there's kind of a included kind of concept, almost like Amazon Prime comes with coke free movies, and we all know they're not really free, but they are included. And so yes, we've just surpassed 0.5 million subscriptions to the license service, which is being activated on behalf of our customers that have hStream for learning in their contracts.

So we're really excited. And then we're converting some of those to upsell to add the other forms of sanction screening. And so -- and meanwhile, because it's an API-driven service, we're infusing those same services into other application sets and so we're really excited overall about these new data-driven services. And I don't have the conversion rate in front of me, but we do have upselling happening.

It's probably less than 10% now, but we do have it where they get "the license service" included with their a stream for learning subscription in their contract. Again, like Amazon includes movies. And then there's a buy ops. We have a sales team that calls and offers them the other forms of sanctioned screening as an additional purchase, and we do have a closure rate on that as well. So we're beginning to see revenues come out of those data-driven license verification, office of inspector general sanction screening as well. And so really excited about the long-term implications of that. And it's great to see the base users surge path to $0.5 million now.

[Vincent Colicchio, analyst]

And a quick one for Scotty. What was the percentage contribution to growth from acquisitions? I know it was small.

[Scott Roberts, executive]

Yes, that percentage is probably going to be around 0.5% maybe of the growth rate. It was just under $0.5 million of the revenue in the quarter.

[Operator]

Thank you. I'm showing no further questions at this time. I'd like to turn the call back over to Robert A. Frist, CEO, for any closing remarks.

[Robert Frist, executive]

All right. Thank you, everyone. To HealthStream's that made this all happen, a great quarter. Looking forward to wrapping up a strong year-end. The analysts that cover us. Thank you for telling our story and potential investors out there, we hope you take a look. We're trying to get good shareholder returns here with this dividend and deliver strong operating leverage, particularly in our free cash flows and EBITDA metrics. So excited and look forward to next quarter. Thank you, everyone, for participating.

[Operator]

Thank you. Ladies and gentlemen, this does conclude today's conference. Thank you all for participating, and have a great day. You may all disconnect.