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HealthStream Inc
Earnings Call Analysis
Q4-2023 Analysis
HealthStream Inc
Despite some connection issues during the call, the company shared excitement over achieving record top line revenue of $279.1 million and a record adjusted EBITDA of $61.3 million for the full year 2023. For 2024, they anticipate exceeding these numbers as they continue to expand their product ecosystem, sales channels, and target markets. Further, their NurseGrid app, the most popular app for nurses in the Apple store, helped in significantly reaching and selling to individual nurses, resulting in over 1,800 orders for products like ComplyQ and CE Unlimited during the latter half of the year.
The fourth quarter saw a substantial 31% growth in revenue from their scheduling application, ShiftWizard, with new customers like Norman Regional Hospital joining their roster. Additionally, their credentialing, privileging, and enrollment application, CredentialStream, grew an impressive 52% in the fourth quarter, securing 37 new customers, which include renowned organizations like Intermountain Healthcare, Lyra Health, and Dayton Children's Hospital.
The fourth quarter financials reflect steady growth with a 3% uptick in revenues to $70.6 million, while operating income and net income ballooned by 38% and 87%, respectively. Adjusted EBITDA increased by 17% to $16 million, owing to a shift in revenue mix more towards subscriptions and despite declines in products like the ANSOS scheduling suite. The 2024 guidance projects revenue between $292 million and $296 million, an adjusted EBITDA between $64.5 million and $67.5 million, and capital expenditures between $28 million and $30 million, signaling a growth rate between 4.6% and 6.1%.
Operating expenses, excluding cost of revenues, nudged up slightly due to depreciation and amortization. G&A and sales and marketing expenses dropped by 6% and 1%, respectively, contributing to an improved adjusted EBITDA margin of 22.6%. The balance sheet remains healthy with cash balances over $71 million, no debt, and impressive free cashflows, which will support the company's capital allocation strategy, including M&A, dividends, and share repurchases.
The business highlighted their successes in directly reaching healthcare professionals, such as the over 2,700 orders for new DEA-mandated opioid courses and growth in nurse-targeted sales through NurseGrid Learn. They have decided to retire the hStream subscriptions metric, as it no longer provides a direct correlation to revenue and will instead focus on financial performance driven by the scale of their platform.
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Good morning, and welcome to HealthStream's Fourth Quarter and Full Year 2023 Earnings Conference Call. At this time, I would like to inform you that this conference 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.
Thank you. Good morning, and thank you for joining us today to discuss our Fourth Quarter and Full-Year 2023 Results. Also on the conference call with me this morning 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 could involve risks and uncertainties that could then 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.
Good morning, everyone. I'm having a few connection issues, there might be a glitch here and there. We'll push through it that will the best we can.
[ Technical Difficulty ]
I'm really excited about how we finished the full year 2023. There are lots of exciting things to cover, and we'll do that in great detail over the next 30 minutes. We delivered record top line revenue of $279.1 million and record adjusted EBITDA of $61.3 million.
In our guidance for 2024, we expect to surpass both of those high watermarks as we further expand our ecosystem of exciting new products, new sales channels and new target markets. The significant development in our market expansion
[ Technical Difficulty ]
we also amplified our ability to reach and to sell the individual nurses, through NurseGrid Learn, which is linked via our popular NurseGrid app. As a reminder, NurseGrid is the #1 most popular app for nurses based on ratings and downloads in the Apple store. With approximately 1 in 6 nurses in the U.S. regularly using it.
During the third and fourth quarters in 2023, over 1,800 orders were placed by nurses. Some of the top products sold
[ Technical Difficulty ]
ComplyQ and CE Unlimited.
Yes, I'm having some connection issues I'm getting feedback from. So again, we'll push through best we can. I'm excited about our early success in selling direct to health care professionals with our new e-commerce enabled hStream platform. I believe that the ability to participate in our ecosystem throughout one's health care journey
[ Technical Difficulty ]
new opportunities for caregivers to advance both their skills and
[ Technical Difficulty ]
reminder about our business and who we are for the benefit of anyone who is new to HealthStream.
First and foremost, HealthStream is a health care technology company, dedicated to developing, credentialing and scheduling the health care workforce through SaaS-based solutions. Each of which are becoming more valuable because of the interoperability they're achieving through our hStream technology platform. Historically, we sell our solutions on a subscription basis under contracts that average 3 to 5 years in length, which,
[ Technical Difficulty ]
In fact, 96% of our revenues are subscription-based.
As I just mentioned, we have also started to open our sales channels directly to health care professionals and nursing students, across the continuum of health care training. We are profitable, have no interest-bearing debt and a strong cash balance of $71.1 million. We're solely focused on health care, and more specifically, the health care workforce. The 12.3 million health care professionals and nursing students in the United States, comprise the total addressable market for our SaaS,
[ Technical Difficulty ]
All right. I'm going to need to,
[ Technical Difficulty ]
it looks like we're having bigger connection issues than I thought. So I apologize for that. I'm going to have to go find another dial-in, if you can give me just a second. Molly, I'm going to ask if you can hear me that you pick up since the script is written. If you could pick up in the paragraph or maybe even -- since you know where I dropped.
Yes.
Go ahead and start from the top.
So I'll start where Bobby left off, if I understood that correctly. So in the fourth quarter, revenues from our scheduling application, ShiftWizard grew 31% over the prior year quarter, as customers continue to report high customer satisfaction. Since purchasing ShiftWizard in October 2020, we have selected it as our primary scheduling application and significantly expanded its ability to perform at enterprise scale, and it's only going to become more powerful and more differentiated in the market in the coming year.
In the fourth quarter, we welcomed many new customers for ShiftWizard, including Norman Regional Hospital, Freeman Health Systems and Phelps Health. Revenues from credentialing, privileging and enrollment application credential stream grew 52% in the fourth quarter versus the same period last year. In the fourth quarter, we contracted 37 new customers for our CredentialStream solutions. These new CredentialStream customers included many highly respected health care organizations like Intermountain Healthcare, Lyra Health and Dayton Children's Hospital. So there's still a great deal to talk about. But right now, I'm going to turn it over to CFO, Scotty Roberts, for a more detailed look at our financial performance and expectations.
All right. Thanks, Mollie, and good morning. I want to start my portion of the call today with a recap of our financial results for the fourth quarter, and then I'll go over our financial outlook for 2024. Unless otherwise noted, the comparisons will be against the same period of last year.
We continued to deliver solid results as we closed out the fourth quarter of 2023. Revenues were $70.6 million, up 3%, operating income was $4.3 million, up 38%. Net income was $4.6 million, up 87%. Earnings per share were $0.15 per share, up from $0.08 per share. And finally, adjusted EBITDA was $16 million and was up 17%.
Our revenues increased by $2.1 million or 3%, coming in at $70.6 million compared to $68.5 million in last year's fourth quarter. Our revenue mix continued to tilt from the direction of subscriptions versus professional services. In fact, revenues from subscription products accounted for 96% of total revenues and were $67.9 million, increasing by 4% in the quarter.
Professional service revenues declined by $0.5 million or 17%, which had a negative impact on our growth rate of approximately 80 basis points. So now let me provide some more color about the revenue results. As Bobby and Mollie mentioned earlier, we saw a good mix of growth contributors throughout our portfolio, but I want to call out and quantify a couple of areas that kept our growth rate for the quarter, lower than it would have otherwise been and lower than we expect to see it in 2024.
The first area that I'll highlight is associated with our ANSOS scheduling products. The suite of products was down $0.5 million or 13% in the quarter. Our focus continues to be on stabilizing existing ANSOS customers and migrating them to ShiftWizard, our SaaS scheduling application, which grew its revenue by 31% in the quarter.
Future declines associated with the remaining $14 million of ANSOS-related revenue are contemplated in our 2024 guidance. The second area that I want to mention is our Quality Manager solution, which accounted for approximately $5.5 million of subscription revenue for the full year of 2023, and it was down $0.4 million or about 23% in the quarter. We acquired this product in 2019 and unlike most of our products it's sold to the skilled nursing facility market. And while most areas of health care have rebounded since COVID, skilled nursing facilities, in particular, have continued to experience financial pressures.
ANSOS, Quality Manager and Professional Services declined, offset some of the exciting growth that we experienced in products like CredentialStream and ShiftWizard. Now our remaining performance obligations were $541 million as of the end of the year compared to $517 million the year before. We expect approximately 42% of the revenue backlog to be converted in 2024. Our gross margin was 66% compared to 65.7% last year, and this was in the range that we expected.
Moving on to operating expenses. The reorganization of the business, as a single operating segment, at the beginning of the year led to efficiencies and cost synergies in our operations that are reflected in our financial results for the quarter. We were able to maintain our operating expenses, excluding cost of revenues to a modest increase of $0.4 million or 1%. And most of this year-over-year increase was from depreciation and amortization, which was up 10%, and product development was up 1%.
Our G&A and sales and marketing expenses were down 6% and 1%, respectively. Adjusted EBITDA was $16 million, which was up 17%, and adjusted EBITDA margin improved to 22.6% compared to 19.9% last year. Now let's go over the balance sheet metrics. We ended the quarter with cash and investment balances of $71.1 million compared to $71.8 million last quarter. During the quarter, we deployed $6.6 million for capital expenditures, paid $0.8 million to shareholders through our dividend program, and we repurchased $6.8 million of our common stock under the share repurchase program announced in September.
For receivables management or days sales outstanding of 42 days for both the fourth quarter of this year and last year. While we've had a relatively steady performance with receivables, during the past year, our bad debt charges increased by approximately $600,000, of which about $350,000 occurred in the fourth quarter. Our total bad debt charges for the full year approximated $1 million or about 0.37% of revenue.
Now switching over to cash flows. For the full year, our cash flows from operations improved by $12.8 million or 25%, coming in at $64 million, and free cash flow has improved to a record high of $36 million, compared to $26.1 million last year, an increase of 38%. We have a strong balance sheet with over $71 million of cash, no debt and improving free cash flows. With available capital to deploy, we apply this disciplined approach to our capital allocation strategy, which includes M&A, dividends and share repurchases.
While we did not complete any acquisitions during 2023, we maintained an active M&A program to evaluate potential transactions that fit our investment criteria. In addition, deploying capital through cash dividends and share repurchases are wise ways to improve shareholder value. In February of 2023, our Board of Directors adopted a dividend policy, which we returned $3.1 million of cash, back to shareholders last year.
Yesterday, our Board of Directors declared a quarterly cash dividend to be paid in March, increasing the payout by 12% over the previous quarterly dividend. As for our share repurchase program, during the quarter, we made $6.8 million of share repurchases, and we have $1.1 million remaining under the program. Our current share repurchase program will expire on the early of March 31, 2024, or when the maximum dollar amount under the program has been extended.
In the fourth quarter, hStream subscriptions increased by 85,000, over the previous quarter to a total of approximately $5.8 million. Now as we turn our attention to metrics that are more relatable to revenue growth and our medium-term financial objectives, we are planning to retire the hStream subscriptions metric with this report. We believe that hStream subscriptions have served as a good indicator of our ability to deploy our platform at scale, and we are now turning our attention to the future financial performance that scale can drive.
As we've said before, hStream subscriptions are not intended to be used to calculate revenue per subscription or revenue per subscriber. A key reason for that is because not all products that result in revenue gains or losses require hStream subscriptions and subscriptions do not necessarily correlate on a one-to-one basis with subscribers.
We continue to believe that the medium-term financial objectives that we introduced at our September 2022 Investor Meeting are key performance indicators for our business. So let's refresh on our medium-term objectives. Metrics, which support them and our performance against those metrics in 2023.
Our revenue growth objective is to be in the 7% to 10% range, with 5% to 7% coming from organic growth and 2% to 3% from inorganic. For 2023, we achieved revenue growth of 5%. Our gross margin objective is 65% to 68%, and we achieved 66%. And our adjusted EBITDA margin objective is 21% to 24%, and we achieved 22%. We're excited to now give our financial guidance for 2024, which we expect to deliver on each of the 3 medium-term objectives, I just described.
We expect consolidated revenues to range between $292 million and $296 million. We expect adjusted EBITDA to range between $64.5 million and $67.5 million and capital expenditures are expected to range between $28 million and $30 million. This guidance does not include assumptions for any acquisitions that we may complete during the year. Our revenue guidance range implies a growth rate between 4.6% and 6.1%, and we expect steady performance across the year.
Our ability to upsell and cross-sell solutions to existing accounts, improve our revenue retention and acquire new customers, including targeting the nursing school market and increasing sales through our commerce channels are elements that we believe will help us achieve these revenue targets.
We expect gross margin to be around 66% for the year and subscription revenue mix from solutions that we own versus partner solutions, which we pay royalties and investments in our platform infrastructure, such as cloud hosting and software will be the primary influences on gross margin.
As for staffing, we have just under 1,100 employees and approximately 50 open positions, as of the beginning of the year. So labor costs are expected to increase steadily across the year. We expect both product development and sales and marketing to increase in the 4% to 6% range. We have plans to increase our marketing efforts this year, including our trade show presence and engagement directly with the students and professionals.
We expect that our G&A costs will increase 1% to 2%. And finally, we estimate the effective tax rate will be in the low- to mid-20% range. That concludes my comments for this quarter's call. Thanks for your time this morning, and I'll now turn the call, hopefully, back over to Bobby for some additional updates.
Okay. Great. Thanks Scotty, I think I'm on a better connection now. I have to have a little discussion with my Google connection, but we're good to go. What I'm going to do is repeat my opening section because we need a good record of it. And then I'll pick up with the third section, my final section. If I break out again, I'll ask Scotty to do the same. Just go back to the top of the script and get my first section in the record and finish with my -- the third section of our presentation.
So good morning. Thank you, Mollie, for the handoff earlier. Welcome to our Fourth Quarter and Full Year 2023 Earnings Call. I'm excited about how we finished the full year 2023. We delivered record top line revenue of $279.1 million and record adjusted EBITDA of $61.3 million. In our guidance for 2024, as Scotty just mentioned, we expect to surpass both of those high watermarks as we further expand our ecosystem with exciting new products, new sales channels and new target markets.
A significant development in our market expansion strategy in 2023, is our additional focus on selling directly to individual end users like physicians, nurses and nursing students. Our hStream platform now allows us to approach individuals with a learning most applicable to them. I want to check real quick and see how that came through. Scotty? Or Molly?
You're coming in just fine, Bobby.
Okay. Great. Around midyear, we began selling primarily to physicians on our newly released CME courses site, powered by the hStream platform. On that site, we've seen a surge in site visits and purchases with the most popular purchase being the new DEA-mandated opioid course, with over 2,700 orders placed in the fourth quarter alone.
During the last 2 quarters in 2023, we also amplified our ability to reach and to sell to individual nurses through NurseGrid Learn, which is linked via our popular NurseGrid app. As a reminder, NurseGrid is the #1 most popular app for nurses based on ratings and downloads in the Apple Store, with approximately 1 in 6 nurses in the U.S. regularly using it.
During the third and fourth quarters of 2023, and powered by our new hStream commerce capabilities, over 1,800 orders were placed by nurses. Some of the top products sold directly to nurses via NurseGrid Learn include our stable program, our regulatory courses we call SafetyQ and ComplyQ and CE Unlimited.
I'm excited about our early success in selling direct to health care professionals with our new e-commerce-enabled hStream platform, I believe that the ability to participate in our ecosystem throughout one's health care journey, including as a student, which is a new target for us, when they're an employee at a health care facility, or as an individual finding us between jobs even now with this new commerce capability, we kind of create a continuous revenue opportunity out of the millions of subscribers in our network.
And I think this gives them opportunity to kind of continuously develop them and engage with our ecosystem throughout their career. Before we go further, I want to provide a high-level reminder about our core business and especially for the benefit of those who may be new to HealthStream.
First and foremost, HealthStream is a health care technology company. dedicated to developing, credentialing and scheduling the health care workforce through SaaS-based solutions, each of which are becoming more valuable as they become increasingly interoperable through our new hStream platform technologies.
Historically, we sell our solutions on a subscription basis under contracts that average 3 to 5 years in length, which makes our revenues recurring and predictable. In fact, as of today, 96% of our revenues are subscription-based. As I just mentioned, we have also started to open our sales channels directly to health care professionals and nursing students across the continuum of health care training. We are profitable, we have no interest-bearing debt and a strong cash balance of $71.1 million.
We are solely focused on health care and more specifically, the health care workforce. The 12.3 million health care professionals, which now include about 1 million nursing students, in the United States, comprise the total addressable market for our SaaS solutions. In the fourth quarter, revenues from our scheduling application, ShiftWizard, grew 31% over the prior year quarter, as customers continue to report high customer satisfaction, since purchasing ShiftWizard in October of 2020, we've selected it as our primary scheduling application and significantly expanded its ability to perform at enterprise scale and is only going to become more powerful and differentiated in the market in the coming year.
In the fourth quarter, we welcomed many new customers for ShiftWizard including Norman Region Hospital, Freeman Health System and Phelps Health. Revenues from our credentialing, privileging and enrollment application CredentialStream grew 52% in the fourth quarter versus the same period last year. In the fourth quarter, we contracted 37 new customers for our CredentialStream solutions. These new CredentialStream customers included many highly respected health care organizations, like Intermountain Healthcare, Lyra Health and Dayton Children's Hospital.
There's still a great deal to talk about. And since Scotty has covered his section, I'm going to jump right down to my concluding remarks. One second. All right. Now during investor call in October, I mentioned that we grow our business by expanding market share and increasing wallet share. In the first half of the call, I talked about expanding our markets by selling directly to an audience of physicians, nurses and nursing students. Now I want to provide a good example how we expanded wallet share through better retention strategy, expansion and cross-selling at a key customer account during the fourth quarter.
One of our valued customers on the West Coast, chose to expand their learning center and hStream subscriptions from 6,200 users to about 8,000 users. They also renewed their purchases of several content offerings like their health equity and belonging education for their staff, the checklist software tool they use for different compliance efforts and competency validation, their SafetyQ and ComplyQ, again, regulatory training content and even EBSCO's clinical skills program and Dynamic Health.
Not only did this customer commit to a long-term 5-year renewal on those products, they decide to further leverage the power -- the hStream marketplace by adding our CE Unlimited product with the jane AI technology.
And I just love that this customer continues to trust HealthStream for their kind of the more complete education and training of its workforce. So you heard that some of this was in compliance, some in clinical skills, some in soft skills and business skills. So exciting to see the breadth that they use us for that area.
But in Q4, the customer actually also purchased ShiftWizard, our scheduling application. And this is the first time they've entered that part of our ecosystem, using our ShiftWizard application. So I'm encouraged by the cross-selling that occurred when the ShiftWizard purchased -- because it represents how we're focused on that cross-selling effort in all of our accounts. But in particular, this one was exciting.
And I'll end this example by noting that the recurring revenue from this customer grew by 55%, through that renewal process to about $216,000 in the quarter. So it's a pretty good sized account. And it grew by 55% when it renewed and it added not just more learning products, but also the cross-sell or the upsell, the purchase of the scheduling applications. And we're really excited because now we're beginning to demonstrate how those applications -- now although limited and powered by new hStream technology, some limited capabilities of how our different systems can work together.
I do want to talk just for a minute about our evolving AI strategy. Going forward, we expect AI to impact how we develop products, the capabilities of our products and even kind of some of the models for our products, like the learning model gets adjusted with the application of AI technology. So we're really excited that we're making incredible progress with our jane AI products.
And we really are putting our energy and AI around the jane platform, which is used to develop and identify competency gaps for nurses. So it's a really great place to apply AI technology because we have proprietary taxonomies, that can be used in navigating a custom pathway for someone.
We can use the natural language processing to interpret their written feedback and when they take our jane AI competency testing. And so this product is really exciting over the last 24 months. We've received numerous awards since its introduction. And in the fourth quarter, it was recognized for 3 more prestigious national awards, bringing the total number of awards for jane to 11. And so I'm definitely excited about this award-winning product and its recognition for pioneering new methods of learning and application of AI to the learning journey.
And what I'm most excited about though is that, in the next quarter or so, we're bringing a new version of jane to market that's specifically tailored for nursing students. And if you remember, last quarter, we announced that we were going to target the nursing school market and the nursing students in that market. And I think the new version of jane that we're preparing to that market is going to be particularly impactful for those students early in their career.
And so we're really excited about our emphasis on the use of AI and the learning journey, in particular, the award-winning jane product and the new modifications that products make it appropriate for both professional staff and hospitals and nursing students in nursing schools.
In closing, I do want to highlight that our Board recently approved, or just yesterday, an increase in the cash dividend to be paid out to shareholders. They approved the dividend payment of $0.028 per share, which is about a 12% increase over the previous quarter's dividend of $0.025. The upcoming dividend is payable on March 22, to holders of record on March 11. And so if you're not in the stock, you can still come in and earn that dividend and go on this journey with us.
We continue to be confident in our ability to accomplish our innovative organic and our inorganic growth strategy, as we mentioned, we have about $71.1 million of cash, while also returning cash to shareholders as part of our objective. So we're excited about the dividend program.
If you're interested in a profitable, highly recurring revenue SaaS/PaaS health care technology company that for 2024, expect to deliver steady growth and is determined to share some of its gains directly to shareholders in the form of a dividend, one that we just increased, maybe HealthStream as a company in stock for you. And so that's my marketing pitch. I've always got to do a little bit of selling.
Look, we're on the journey together and I've been building this company for a long time, and I've never been more excited about the prospects for the company, as our technologies evolve and incorporate the latest like the evolving AI landscape. And our teams are amazing. We have 1,100 employees that are building incredible products and taking them to market with great passion. So we're really excited as we launch into this new year.
I'll turn it over to the operator for Q&A. I hope that, that came through, if it didn't, we'll probably have to schedule another day like an Investor Day or something to make sure we get all this great information on the transcript.
I'll turn it over to the operator for questions.
[Operator Instructions]
And our first question comes from Matt Hewitt with Craig-Hallum.
Maybe first up, just a point of clarification. I think, Scotty, you mentioned there was $14 million left in ANSOS legacy contracts. I'm just curious, will those contracts be up for renewal or conversion, I guess, this year? Or does it expand beyond this year? I'm just trying to figure out what the headwind is, that you're facing maybe a little bit this year.
I'll start. I'll take that and then let Scotty add to it. The total remaining kind of business with ANSOS is about -- is $14 million. And it is our hope and expectation and our work and focus of our work to retain all that business, until which time we can eventually upgrade them to the newer technologies like ShiftWizard.
And so it is our objective. Now that said, in the last 24 months, as Scotty noted, we've experienced attrition in that group and lost them, not to the market, not to the translation over to ShiftWizard. So, we're working really hard to position the upgrade to ANSOS at ShiftWizard.
If you remember, it's a legacy installed product. It is aging technology, and we're working hard to keep the customer satisfied with where they are, renew them as their contracts come up for renewal and -- but also transition them when they're ready to transition to the ShiftWizard product. So we hope to stem some of this rate of loss here in the coming quarters. And get them transitioned over to ShiftWizard as well. So I hope that set a framework, and if Scotty wants to add anything, he can.
Yes, Matt, I mean it's a mix of contracts that are what we call in their auto renewal phase. That's a common practice for that type of previous sale and then a good mix is also as customers that have entered into agreements for multiple years of renewal for that solution. So it's -- I don't have the numbers in front of me to speak to, but there is a mix of contract lengths in the base.
Got it. That's helpful. And then, Bobby, as you look at -- as you start to sell more and more directly to the end user, particularly the nurses. Historically, you've signed, and I think you mentioned again today, you're typically signing 3- to 5-year contracts with your hospital customers. But with nurses, in particular, are those -- those aren't 3- to 5-year contracts.
So how does that change your visibility? And what can you do to ensure, obviously, it's a big market. And getting in early with those end customers is obviously ideal. But how does that change your visibility? And what can you do to maybe increase that?
Yes. A couple of things. One, these technologies power commerce, B2B e-commerce as well as direct-to-consumer. And so there's 2 opportunities here. And the main one I'm going to cover first is, focusing on the nursing students, while they're in the 2- and 3-year programs to become nurses and getting the schools to have the commitment to put those nurses through kind of -- those nurse students through ready-to-work programs.
And so the main focus of this is to get it where they could both be -- find a clinical rotation in a hospital, and of course, they pay a little fee for that through My Clinical Exchange, buy a few content bundles like the Red Cross program before they become a nurse. So they enter the market with the certificate. And the certificate generally has about a 2-year lifespan.
And we've entered into at least one major multiyear contract with a nursing school that has committed to provision some of these services to the students on a steady basis, ongoing basis, before they become a nurse and then as they transition from there, they can carry using the hStream technology, that portfolio, that record forward with them into work. So that's the main focus of these commerce capabilities, the new student jane AI, for example, we'd rather the school contract to provision it to the students.
Now the second capability is the one I opened with, which is fun and exciting. It's kind of a gap filler. So if someone is between jobs, they noticed their license might expire, if they don't take certain education -- for their continuing education, they can still use their hStream ID, log in and pay for themselves, of course. And we did report on a lot of activity on there, both by learning to target doctors and students.
That revenue will be a little less predictable. It is good margin and it is incremental. And it's picking up a gap, say, between jobs or when they're not working in a place to use our enterprise software. So it's kind of a gap filler, I call it money-while-we-sleep, because it's all automated, credit card purchases.
It will be less predictable and -- but you can see that we filled a lot of gaps in the fourth quarter with both of those types. So the emphasis will be, of course, on the B2B engagement with the schools, that are interested in developing nurses, the students and the nurses and then placing them in their first jobs in hospitals. So that will be the real focus.
And we mentioned the modified jane product that's coming out and our initial -- we have initial big win with a big nursing system that has committed to put -- we believe they're piloting to put all their students through the jane program, and we'll see -- we'll know more about that pilot at the end of the year, but that will be the real B2B goal as well. Hope that helps clarify.
But that incremental revenue that we opened with is just fun and exciting incremental revenue for content we already own, to audiences that would have normally disengaged with us, say, between jobs. So if a nurse worked at a hospital on our learning system and built a transcript, they take 6 months off and then they take another job at hospital that also uses HealthStream, they could pick up their education there.
But now with our commerce abilities, they might in between that, log in directly and consume a course may be required by their state licensure. And so it's a gap filler and a time filler, it's incremental. It will be a little less predictable, but it is good margin. So I hope that helps, at least understand what we're going for. And it's a little bit of context, too, for the concept of trying to make all of these business subscriptions and the people behind them, kind of continuous lifetime customers of the HealthStream ecosystem. And so hopefully, it kind of clarifies that gap filling capability we have, and it will be a boost to revenue here and there.
Our next question comes from Jared Haase with William Blair.
This is Jared Haase on for Ryan Daniels. Bobby, maybe just to start, I was hoping to unpack a little more color, just around recent sales cycle trends. It seems like others that we've heard in the health care IT space is starting to flag, maybe some improvements in the selling environment with health systems, maybe relative to what the environment was like going into 2023. So I'd just be curious if that's something you've experienced in any meaningful way? Has that translated into any sort of favorable inflection from a selling perspective?
Yes, sure. It's in different pockets. And so we did try to highlight some of that in the call. I don't know if some of that got muddled out, but let me kind of repeat and think through some of it. I think we did talk about, at least for some of our legacy products, where they had some decline, and we specifically addressed the skilled nursing market. So that market as a whole, is under a bit more duress, we see a little bit more churn in the customer base, like the smaller ones maybe combining with larger ones or even going out of business.
So in the skilled nursing market, it seems to still have some remaining financial stress and a little bit harder to sell to. And so we saw some declines in the product that -- the quality manager product that Scotty mentioned.
And -- but we did also open by highlighting, actually I had to repeat it still at the end, but highlighting the subscription growth to ShiftWizard and CredentialStream, both of which, as you heard, 31% and nearly 50% year-over-year growth. Which is reflected in the strength of the pipeline for those products.
And so I guess I'd say it has some variability. But in some of the bigger enterprise purchasing, particularly in CredentialStream and ShiftWizard, we saw -- we see strong pipelines. And so maybe there are certain subsegments in the market like skilled nursing. We're learning more about nursing schools and their buying cycles. And so there'll be more on that in the future.
So I won't comment too much on that because we both have new products and a new focus on selling to those. But -- so there's some variability in there. I'd say generally, though, the patterns of reviewing products for purchasing, the availability to sell is obviously much improved from the middle of COVID, where people simply weren't taking calls. And so I'd say there are kind of normalized new models of selling and customers are receptive to seeing the new and exciting products that we have.
Okay. That's helpful. And then maybe just one on the 2024 outlook. And looking at the revenue guidance, it looks like the range from the low to the high end is a little bit narrower relative to the guidance for 2023. I'm curious if there's anything we should infer in that, just in terms of the level of confidence that you have at this point in the year, maybe relative to last year or anything that's changed from a visibility perspective?
I know you're still working through the ANSOS sort of headwind and maybe there's some nuances as to how that kind of impacts the forecast? But maybe I would just love to unpack anything that's going on from a visibility perspective at this point in the year.
I mean, generally, as we open, the business is very predictable. There are some variables and again, we noted those like ANSOS that are less predictable, we've tried our best to factor in the topics that Scotty covered on some of the challenging areas. And I think in general, we're getting a little better, and I feel a little more comfortable with the slightly tighter range.
And so I guess we're just getting a little better at forecasting. Also, it's interesting in the -- we talked about the direct-to-consumer commerce too. A lot of that's data-driven. And so for example, we mentioned now that opioid course was just selling really well. I mean there is kind of a requirement around that, and we're getting better at the targeting, so we're a little better at predicting those sales, which might normally be considered almost totally or less controllable.
And so I'd say, using better targeting for selling and maturing a bit in our forecasting. We hope that we're able to tighten that range and give a little better guidance. So we'll see how that plays out. But our expectation is that we can hit that range.
Our next question comes from Stephanie Davis with Barclays.
This is Anna Kruszenski on for Stephanie. I want to go back to the 2024 guidance. Just curious if you could talk a little bit more about the drivers of more sequentially stable growth in margins, given your cost optimization and network expansion efforts?
I'll let Scotty take a little of that. I think -- just in general, yes, we've gone -- as we migrated from essentially to this one HealthStream model. We've been able to find operating synergies in the business, by operating more like a single platform company, we were able, in early last year, to restructure some of our operations and de-duplicate some of what we used to be segment reporting. And so some of those efficiencies are still in the model, and we benefited from them this year.
We're just getting better kind of operating. So you see better management of our G&A, for example, in the last 12 months. and therefore, may be more predictable, as we look into next year. We hope, again, more stability -- there are a few variables to that, as we just talked about a few of them in the sales model, Also, a few challenges in submarkets like the skilled nursing. We did see a little higher bankruptcies in the market, which again adds a little bit of variability to the predictability, things that are essentially beyond our control.
But the things that are within our control, I think we're getting better at controlling, both from a G&A standpoint, even CapEx, there's an increased focus on deployment of our capital into software development and a better, I'd say, rank ordering prioritization of projects that we think we're going to be hopefully get better and better at deploying our capital. And so I think all that is just hopefully a maturing business that's getting better at how it operates and studying more for efficiencies on how we get where we're going.
For example, these new e-commerce selling ability are providing more financial leverage, as we sell with click-to-purchase functions, we can lower our total cost of sales. And I think that's kind of another type of efficiency we expect to get, as we deploy the new platform models that we're building.
That's really helpful. And then as a quick follow-up. Just curious if you could rank your capital allocation priorities, across inorganic opportunities, dividends and share repurchases for the next year?
Gosh. Well, I mean, the first priority is building organic products like the jane AI product that is -- we're going to take into the nursing school. So first priority for capital and capitalized software development is in building and enhancing existing products and building new products, we've talked about taking ShiftWizard more to enterprise class. We've talked about adjusting our jane product, enhancing the AI technologies and entering new markets with it.
So our capital -- the bulk of our capital goes into exciting new product development. That is the place where it should go. And then second to that would be, I guess, the inorganic opportunities, and we -- our last acquisition was a little over a year ago. It turned out to be a really strong winter, small bite-sized tuck-in incremental to our platform strategy. So very excited.
And I think that will be kind of the second priority is to -- we won't force anything. As demonstrated last year, we did no acquisitions last year. But we're constantly looking and expect to continue an active M&A program, especially the kinds that kind of leverage our platform technologies and where we're going, the 3 primary application areas where we are.
So anything that strengthens those 3 areas or enhances our infrastructure, our targets for us, so that would be the second. And then I would say, we executed a really good buyback program. I think we've done 3 in our 20-plus years, 24 years being public, Actually, all 3 of those buyback programs are in the money, which I think would be atypical of a lot of management buybacks -- management and Board-driven buybacks.
So all of our buybacks have been good deployments of capital, knock-on wood so far. And so that had maybe the third priority. And that program does lapse in March and no visibility on whether it's time for our Board to put another one in place. But right now, we have an active program that expires in March.
And then lastly, the dividend, I think it's a very small dividend, but it sends the message of capital discipline. I think taking a little bit of money off the top for shareholders. and then applying the balance of it to all the things I just talked about, I think puts a little bit of capital discipline and it says, look, first order to remember is to make money for shareholders.
And we put a small dividend in place to send a very clear message that we can manage our free cash flows, build new products, enter new markets, do small acquisitions that fit, while also paying out a little -- sharing the profits along the journey. It is a journey. I've been doing this a long time. And I think it just brings shareholders more on to the journey to share a little bit as the journey evolves. So -- those would be our 4 priorities, 1, 2, 3, 4, the way I articulate them. Thank you.
Our next question comes from Richard Close with Canaccord Genuity.
Congratulations on a steady 2023. Scotty, I was curious on modeling revenue with 8 streams subscribers going away. Just wondering what's the best way to forecast going forward and how we track the company's progress of penetrating the $12.3 million employee TAM and increased wallet share that you're talking about? I guess, pulling back on the hStream, the model has sort of evolved into a black box. And -- are you considering providing any other metrics like ARR growth or net revenue retention or anything to help us out?
Yes, we're studying that now. So a couple of things there. First is just a reminder. And I think in spite of our best efforts to explain where we are in the journey. I want to remind you, the first thing is that, the metrics that we had out there that we just retired was for subscriptions, not subscribers. And so it really was intended to show the platform kind of expansion, but not as an infrastructure for calculating ARPU or revenue per employee because we haven't yet gotten to the place and we fully intended to, over time, get to the place where we could convert, and talk about subscribers, like the number of unique health care persons in our network.
And we -- and so we're just not -- it was a great metric, almost like for a single product to talk about its expansion. But it was not correlated to revenues for the reasons Scotty mentioned, and it was not -- it doesn't correlate to subscribers, and we saw some potential misapplication of it to calculate revenue per subscriber. And so we think it served its purpose. We're getting our technologies out into the market and almost we report subscriptions sold, our regulatory course where it gave a sense for that, but it is not a proxy for subscribers.
And it can't be related to revenues yet because it's not fully deployed, meaning there are several products that drive revenues that don't add to the subscription number. So for that reason, not -- subscriptions, aren't subscribers and it's not fully deployed. It can't be used as a denominator in a revenue per employee model. So we are going to look to this year, add additional both financial metrics to focus on.
We already report full GAAP, of course. But -- and one of those we're studying is ARR. So we'll look towards the middle of the year to see if we can get to that kind of metric, which I think would help all of the analysts and everyone understand the recurring revenue nature of the business and the growth trajectory.
So yes, Richard, we're working on that. But I think it's time to take this metric, as we mentioned, kind of off the table because it was symbolic of the growth of the platform extension, but not relatable to people yet and not relatable to revenue, and we saw some of that starting to happen.
So we just think we need to move our focus probably towards something like ARR. That was the discussion in the last quarter, and we've got a test -- back test and see how that metric -- how we're going to measure it. but that would be a goal, would be to add some new metrics by the middle of the year.
Okay. Great. That would be helpful. And then on ANSOS, I had I guess a couple of follow-up questions on that. Is the remaining $14 million, is that just maintenance and support revenue? That's the first question. And then if there's any details in terms of the success rate of converting to the ShiftWizard product would be helpful or -- and then finally, the average term, I guess, length -- the time on the remaining contracts?
Sure. A couple of things there. The contracts have a lot of essentially, a lot of them are old installed and they have a maintenance fee that's non-SaaS, but there is some recurring nature to it and they have auto renewals, unless they cancel. And so there is a recurring nature to it. And it does include some those maintenance fees basically. So the second is on the conversion rate. I'd say, to date, obviously, unfortunately, not very successful at all of that, but a renewed focus by our teams.
Also, as we've talked about in prior calls, we're enhancing ShiftWizard to better meet the needs of these enterprise customers of ANSOS. And so -- and I think every single quarter now and actually every month on ShiftWizard, there's a new software release and it's moving us ever closer to full enterprise capability.
So I think it will be a better opportunity to transition. So again, not very successful in the migrations today, as you hear from the loss that we've been reporting, we do expect and we have full energy on stabilizing that $14 million, and we're going to try to reduce the attrition rate and also succeed better this year in the conversion rate. So this isn't a story of I don't think going to 0. It's an effort to stabilize and stem the loss, while also transitioning them to the newer exciting technologies of ShiftWizard.
And ShiftWizard is very well received in the market. For its current capabilities, it's just winning share. We just need to enhance some of its core functionality, and we've made a lot of progress on that, enhancing core functionality around kind of enterprise level data analysis. And so I think we look forward by the middle of the year having great progress on that. So there'll be a better destination, a better destination to migrate everybody to. I'll turn it over to Scotty, if he wants to add anything.
Yes, I'll just make a comment or 2, Richard. I mean, I think, I tried to address with Matt earlier in the call, kind of the nature of the contract length that kind of vary from auto renewals to some that have signed multiyear contracts. I don't have the duration run out in front of me, but there is a good mix of auto renewals plus customers under term.
I would say, too, that our objective is to continue to support the customers. We do want to migrate them to ShiftWizard, but we also want to acknowledge that there are still customers on that application, and we're still there to support their use of it. And so that's another consideration.
And I think as we talked about the $14 million, it's -- we wanted to just provide that number to provide context, as Bobby said, I don't expect it to go to 0. I just wanted to size it up for our investors to understand the magnitude of it.
Okay. That's helpful. And then on the direct-to-consumer, just on that portion of revenue, I know it's small, but it's a different sale. How are you thinking about customer acquisition costs on the direct-to-consumer market, maybe it's a little less than a typical direct-to-consumer because they -- if they're in between jobs, they already have exposure to you. Just trying to get your thoughts on that.
Yes. I would say for the next couple of years, our thoughts are really just to try to keep the people that I would call "in network" to stay in the network when they're between jobs. And as I mentioned, pick up this new audience of students, before they become professionals. And so it really isn't to broadly openly market to people to self-register.
It's to capture using existing data from the customers that have been in network to find them between jobs or when they leave a job, they can now leave and carry their HealthStream transcript with them, and that's different.
And so they kind of -- if they work somewhere for a couple of years and they leave, they can still log back in using their hStream ID and see that they had 10 courses or -- and so now all we're doing is saying, you can log and carry your transcript with you, like a portfolio or a wallet, you can take it with you. But you can also say, well, hey, you now might as well click at the bottom here to keep my license current and take an additional course. And that's happening right now with doctors, on that DEA course that we mentioned, and it's happening with nurses, when they take a little bit of CE or even when they're about to take a new job, they refresh on something before they go back into the new job.
So really, we are -- it's more of a gap filler than it is a broad consumer -- you said consumer, I call it direct-to-professional D2P. And it's really just trying to keep people in network all the time as opposed to just kind of broadly marketing out into the wild open right now. And maybe we get there someday, but really, the job right now is just to make that transcript portable, make them lifetime kind of -- lifetime engaging with HealthStream instead of just engaging with us when they're in their job.
Okay. Very helpful. And if I could slip one more in. I thought on credential stream, it was interesting you announced Lyra Health, a digital health company. That seemed a little bit different. Are you seeing an uptick in opportunities in that segment on the direct-to-employer benefits area?
We are seeing, at least with the insurers. We're seeing some opportunity there. And so I would say, yes, kind of categorically, we -- there's interest in a couple of areas that maybe are not just purely the acute care hospitals. And so there are a lot of -- I guess, I'd characterize them as new, but I just say we're getting better at pursuing a broader opportunity and not just the acute care hospital market. So the answer is yes.
Our next question comes from Constantine Davides with Citizens JMP Securities.
Just a couple of follow-ups here on scheduling. Can you just maybe characterize where you're seeing growth with ShiftWizard because it's been pretty impressive in '23? And I guess just a little further on that? Is it sort of large IDNs, complex academic medical center type installations or smaller hospitals? And then are you typically replacing a manual kind of homegrown scheduling system or some other stand-alone technology solution?
Well, a couple of really interesting things in that space for us. One, I would just describe it if there's kind of such thing as the very large enterprises. And then there's the middle market and then there's the small urban or rural hospitals and community hospitals. It's kind of the middle there that we're getting really strong on.
You probably call them regional health systems. The other thing is that we have this great relationship that's growing with Workday, where they're bringing us in to help kind of them have a complete offering, and we turned out to be really good partners in supporting customers' needs. And so we're getting brought into Workday accounts to -- with them to round out services, and we just found that to be a great partnership.
So kind of a good referral, almost a referral program for us, a good source of leads and compatibility. We just work really well with that team and our applications work together well and present well together. So that's been really exciting and fun. Usually, we're taking out competitors in the market that have aging technology, and we've got this emerging new good paradigm, great user interface with ShiftWizard.
So organizations like UKG and API where we compete, we generally are replacing something. And so I hope that answers your questions. And in general, we're trying to expand the capabilities of ShiftWizard to handle ever larger and larger systems.
We do have some large systems, as customers and we just need a more robust -- basically reporting a data analytics suite, which we have in learning, which is great. So we're going to use a lot of that infrastructure to launch a better class of data analytics and learning around scheduling, which we think will meet the needs of even the larger health systems. So we're excited about that. And that should be a this year event. We're making good progress on that as well.
Again, as I mentioned, with monthly releases of ShiftWizard, very exciting. We have a webinar and hundreds of people attend for each monthly release to see what's coming on ShiftWizard. And it's just gaining traction and momentum and excitement as we add enterprise class features so we can go after even larger customers.
Great. And then -- just a follow-up, I guess, to Richard's question around metrics. Have you -- or can you talk about just how many hStream IDs have been claimed at this point? Is that something you can provide?
It's interesting. It's over 1 million, but we've got a lot of work to do. There's a lot of -- and we've been building tools for a long time now, de-duping tools. We've been building tools to let people -- if they worked at one health system, they can claim their records on another and combine them, so they have this unified transcript as an individual. So it is really exciting, but it's kind of still nascent.
I mean, there are several steps in the process. First, we have to wire the application, we have dozens of applications to the hStream architecture, using -- so it uses the hStream ID. And then we have to get the professionals to kind of claim any other uses like we call it putting keys on key chains. So once you have an hStream ID, you're able to then go and say, I also use this application and so kind of merge that information, almost the way you do at Google where you get universal access to all their apps. But for us, it's a limited set of apps now.
So we have over 1 million, what I'll call reconciled IDs and there's going to be millions more over time, but that is going to take time, and that's -- until we can get to that pure subscriber count. Historically, you think of us as a B2B software, 3 separate tech stacks. But increasingly, the tech stacks are interrelated through the hStream platform and the hStream ID. And we're kind of mid-stages maybe deploying both the technology and the reconciliation of ID.
So over 1 million unique hStream IDs have been issued, which is really exciting, but there's millions more to go, and we expect steady quarterly progress on that. And of course, when we get to some place we're excited, where we have enough momentum, that can become a metric. And that could be the basis for some kind of ARPU. But there are 2 things that have to happen. One, more of our applications have to connect to it. And then more of the users have to reconcile. And we've been building -- this is a very complex topic, and we've been working on it for years.
You have to have the reconciliation tools, the account joining tools, the keys on key chains, the management tool sets, and we're actually getting very good at those in the HealthStream ID deployment models. We're getting very good at all of that. And so we expect it to kind of continue to spool up.
And I guess just last question along those lines. Where do you think you are in the journey, Bobby? Whether it's in baseball terms or some other language. But just having all the apps on the platform common architecture, making them all interoperable and seamless. Just how far along you think you are?
Well, on the baseball analog, and I'm not a huge baseball person, but I'd say third inning, but it's going faster. So it's one of those things that's not linear, like each inning isn't the same length. I think it's the kind of thing that can kind of be maybe geometric or maybe exponential, but definitely geometric where it should go faster than linear. And so while we're in maybe 3 out of 9 innings, the fourth should be faster than the third and so on. So I think it can continue to spool up.
Our next question comes from Vincent Colicchio with Barrington Research.
Most of my questions have been answered. Just curious on the CredentialStream side. With the success you're having, has there been any competitive response in terms of trying to match your differentiation there?
Well, no. We have lots of things to do in our roadmap to continue to differentiate. But right now, I think we've got a really exciting product. And in fact, to the point where, as I mentioned, organizations like Workday are thinking of us as a best of breed and bringing us into their deals. So I'm excited about where it is. Now where it's short is, and we talked about this is, some of it's enterprise feature sets, particularly around data management reporting.
Like if you're a large organization with 50, 60, 70 hospitals, you have different demands on how you distribute information, and you're solving labor issues across markets and across regional deployments. And so we're going to get more sophisticated on that this year. but those are the advances that we have. Now the true differentiators are still yet to come.
So we're beginning to incorporate some of the technologies of our platform, for example, the license service. I hope that by the end of the year, for example, we'll be using the license service that was built in CredentialStream to verify nurses license before we schedule them. And so we have that capability, as you know, in our platform to check licenses.
And so it will be a further differentiation as we connect ShiftWizard to services like the license verification service that is a function of our hStream platform. So that's an example of a differentiation yet to come, that I hope is this year, that will continue to distinguish us from our competitors. And there is, of course, the road map full of those ideas as well.
Vince, were you asking about CredentialStream, on that -- your question?
I think he was actually, or I just got a note from someone. So I guess the same holds true for CredentialStream as it takes advantage of connectivity to the learning center, for example. We're in the middle of going back to customers that have both our learning system and our credentialing system and showing them the interoperability of the early stages of interoperability between those.
For example, how logical is it? But if you earn a credentialing to learning network, it should auto populate as a credential into your credentialing system. And so the same kind of answer holds is that, there are plenty of differentiations to come this year, that show interoperability and several that are in place now that we're beginning to market actively.
So Bobby, were you just still responding to my question because I got cut off.
I think in both cases, I try to give examples of both ShiftWizard and CredentialStream that are going to be increasingly competitively differentiated by how they access services of the hStream platform, whether it's the hStream ID to create interoperability, for example, your data following you from one system into the other. The example I just gave was a learning credential, earned in the learning system following you into the credentialing system and maintaining its primary source verification status.
Or a scheduling system that relies on the platform technology to check a license before you're scheduled and sort of verify your license is active, before we schedule you. And so those are 2 examples of interoperability that are -- one is actively being marketed and the other is to come this year. But increasingly, the differentiation will come from how these applications interoperate or operate together and how data moves between them and how services built in the platform power up distinguished features in the application.
This is true in learning, scheduling and credentialing. In all cases, we hope to further differentiate it. I think there's also a kind of a broader value proposition of getting these applications interoperable. I think it's more appealing to a COO, a CTO, a CFO, when they see a suite of software working together instead of individual -- separately implemented tech stacks. And so we're looking for operational synergy, implementation synergy over the coming months and years.
And one last one. How would you characterize pricing in the acquisition market? Is it rich? Has it improved? What would you say?
Well, let's see. We didn't do a deal in the last 13 months. And during that, I guess, I would say in the last quarter or 2, I think, a little bit of softening and some excitement, that maybe deal pipelines can pick back up. But the private companies always hold on as long as they can, to the past. And so maybe one of the concerning factors was that in the first half of the year.
But I don't know how to say it. If you have a hot company that's a SaaS model and it's emerging and growing fast, you're going to be able to demand a premium for your business when you sell it. And so I think that is almost always true. Maybe fewer companies meet that criteria, and they're also burning cash. So I think those companies -- there's going to be some deals out there, I think, as companies try to recap at lower market caps in the next year or so.
Thank you. There are no further questions at this time. I'd like to turn the call back over to Robert Frist, CEO, for any closing remarks.
Thank you to our analysts for following our story and helping us tell it. Thank you to our 1,100 employees for making all this happen. We'll look forward to our continued reporting and growth as a company. Thanks for going along the journey, all of you shareholders. We'll see you on the next earnings call.
Thank you for your participation. This does conclude the program. You may now disconnect. Everyone, have a great day.