Good morning, and welcome to HealthStream's third quarter 2021 earnings conference call. At this time, I would like to inform you that this conference is being recorded and that all participants are in listen-only mode. At the request of the company, we will open the conference up for questions and answers after the presentation. I will now turn the conference over to Mollie Condra, Vice President, Investor Relations and Communications. Please go ahead, Ms. Condra.
Thank you, and good morning. Thank you for joining us today to discuss our third quarter 2021 results. Also in the conference call with me are Robert A. Frist Jr., CEO and Chairman of HealthStream, and Scotty Roberts, CFO and Senior Vice President. 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 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. With that, at this time, I'll turn the call over to Bobby Frist.
Thank you, Mollie. Good morning, everyone, and welcome to our third quarter 2021 earnings call. I think context is important as we start the earnings call, so I'm gonna give a brief update on our perspective on coronavirus. The coronavirus pandemic in the United States appears for the moment to be in retreat, and particularly in the markets where we practice, and in the business where we operate. Since the start of September, daily cases have dropped by a third, and daily hospitalizations have fallen by more than a quarter. According to the CDC, approximately 58% of eligible adults in the U.S. have been fully vaccinated. As of October 22, as that number rises, we are hopeful that progress towards beating this pandemic will continue.
I shared some of those statistics to just think through the impact on businesses and a meaningful part of the context is the long and medium and short run impact of COVID on our business behaviors and therefore how we plan and our expenses and allocate our sales organization. I wanna speak to that for a bit. The long run impact of COVID on all business is still being determined, but we can already see some of the permanent changes that are taking effect inside of our company. Like many companies, for example, we have adopted a hybrid workplace approach officially, and this is from a company that was really an in-person company for most of our existence. Now we have a full on hybrid workplace approach.
In fact, all of our offices and resource centers remain closed at this time, but we expect to open them by year-end. Our offices will function as resource centers to employees, which is a little different than thinking of them as a place to work. In those resource centers, we'll hold strategic planning meetings, events, and other special meetings, recognitions for employees, the things that help define a culture that are important. We'll ask employees to travel for those events. It'd be a little different than in the past, where work from an office will be elective, but travel for events might be required to be part of developing our culture as a company. We've learned new ways of selling that incorporate virtual technology to a greater extent, and our customers have embraced this approach as well.
While travel for our sales teams will pick up from the near zero levels of the last 16 months, I wouldn't anticipate that they would occur at the pre-pandemic level. I believe our travel expenses pre-pandemic were nearly $5 million a year, and I just don't see them getting back to that level. However, as we noted, the impact of COVID on our work style, we may see travel expenses go up for business related to what I'll call cultural building and goal setting and performance management meetings by teams and team leaders and managers across HealthStream. It's an interesting dynamic where maybe sales business travel may go down, but because we're a fully remote workforce, we might have some mandatory meetings that are cultural development oriented, bringing on new employees, gathering employees to celebrate accomplishments.
Travel expenses may go up in those more elective categories historically. It's gonna be an interesting dynamic to figure out how that all plays out and to what level each returns based on the new work styles. Another impact that we're all assessing now across each company is, I guess, what's been dubbed the Great Resignation. I think COVID has made many people, including HealthStreamers, reevaluate their personal and work life. For a variety of reasons, most of which are indirectly attributed to the events of the last 18 months or COVID, companies are seeing turnover at record levels. These are companies of all types. Other CEOs I speak with are experiencing very similar turnover issues. HealthStream is no exception to that.
What's interesting is that as people look up, head up from other industries, they find HealthStream an enticing place to work. We've experienced record levels of hiring in the last 12 months, but also very high levels of turnover. The net impact of that is a nearly or only slightly positive headcount increase across our organization. I think, you know, earlier in the year, we had anticipated being able to have the net increases, you know, net of turnover to be much higher, maybe as much as 100 more employees than we've been able to achieve through our hiring in the first three quarters. That's resulted in lower expenses than maybe we had hoped to have. In other words, lower investment levels in people.
We have had net hiring positives, but they're almost marginal compared to our expectations as we entered the year. That is a direct impact of what, I guess, what I'll call the Great Resignation, along with others that have written about it. Again, it's this really strange dynamic where we've never had more people interested in working at HealthStream because they're reevaluating their work life from other places, and we've got these highly energetic new employees coming into HealthStream that are ready to start a new career. Also, some of our employees are evaluating their work life at HealthStream, and they're changing locations. What's really exciting to me is I've seen several of them already on the way back to HealthStream after six months away.
The Great Resignation is something we all have to work out, and the result has been higher turnover and lower expenses than we had originally planned. A little better financial performance attributable not necessarily to good things, but to things like turnover and also some maybe longer run challenges that are created by not having the staffing levels that we had expected to have. We kept every quarter trying to increase the hiring rates, and again, incredibly successful at hiring. Now what we need to see is the turnover rates slow down. I'm hopeful that in the next quarter or two, this will settle out a little bit, and we'll continue to get hiring head back in the right direction on hiring.
I wanna talk about those short, medium, and long-term impacts on COVID. They create quite a challenge for forecasting even though they're because nature of work has changed, the nature of travel will change, the nature of where people want to work and how they want to work is changing. I think HealthStream will be, in the long run, a net beneficiary of all these changes. The virtualization of the workforce, we've been highly successful at running our operations and building our business. But like all you know, when major challenges occur, like this pandemic, it creates different gaps in how you're operating in your learning curve and can result in operational challenges over time. We're working through all those in at the present time.
I'd like to spend a few minutes talking about financial performance and turn it over to Scotty, and maybe some context for our financial performance. First I'll hit just a few of the highlights. Since I ad-libbed so much, I'm a little off script, so now I'm back on. Top line revenues increased by 5%, increase of Adjusted EBITDA and 15% over the first nine months of last year. Revenues 5% and Adjusted EBITDA 15% over the first nine months of last year. Again, solid financial performance again in the third quarter. The third quarter revenues were $64.1 million, which is 5% over the same period last year.
This quarterly increase reflects the substantial growth that was necessary to offset and rise above the previously announced anticipated headwind of the $9.2 million decline in the quarter in legacy resuscitation revenues. Again, we've talked about this for almost three years or more, this decline of a partnership and this legacy resuscitation revenues. In the quarter, a - $9.2 million. It's one of the last quarters of material impacts for these declines. We were able to overcome that and deliver 5% growth from a mixture of organic and inorganic work over the last year. Fantastic to deliver growth in the face of such headwinds. Based on these results, we've updated our financial guidance for the full year.
We now expect revenue for the full year 2021 to be in the range of $255.5 million-$257.5 million. We've increased the bottom of the range. We have a little more confidence in the range and the higher end of the range. I believe one of the most remarkable things about this guidance is that we are projecting revenue growth despite a anticipated full year impact of $38.4 million in revenue decline from the legacy resuscitation product. We began the year knowing that we'd have a $38.4 million hole to fill, and I'm really proud of our teams, the types of growth we've delivered on lots of exciting new products, acquired products as well, has been really fantastic.
Again, I'm excited about that result. We also had a negative impact of $4 million of acquisition-related deferred revenue write-downs, so we overcame that as well. I guess, the way deferred revenue write-downs have happened, that'll come back in over the course of the next 12 months into our revenues. That's a good thing. That'll help put a little growth into the future. Additionally, we now expect EBITDA for the full year 2021 to be in the range of $51 million-$53 million. That's up from our last expectation of $48 million-$50 million that was announced last quarter. Now, some of that continued outperformance is based on our inability to hire. Again, we do have a net positive hiring, so we are net growing our headcount, just not at the levels we had expected.
I'll just kind of comment again that there's kind of this lag effect of COVID as we work through the Great Resignation. Again, I wanna emphasize that really record-setting levels of hiring new, excited employees into HealthStream and the outcome is a net positive add headcount. We're not declining any, by any means, but we're also not adding as many as we had hoped. Some of that outperformance is attributable to that change in net hiring. There's some new factors that have helped contribute to the increase in Adjusted EBITDA, and I'll comment on those. For example, year-to-date revenues benefited from legacy resuscitation and perpetual software sales, which we expect to be less impactful during the fourth quarter.
There's a little bit of leftover legacy revenue that was maybe more than expected and a little bit of perpetual software sales from some of the acquired products that we're trying to move to SaaS and subscription selling, hopefully soon in the next year. Some of that will be not repeating in the fourth quarter. Additionally, the macro workforce trends, which I've covered in great detail, made it difficult to increase headcount as quickly as we had planned. We now anticipate that in spite of three quarters of trying, we're gonna just say we expect that trend to continue through the end of the year. We probably won't be able to make up all the hiring we had planned throughout the year in the remaining quarter, and our new guidance reflects that assumption.
We'll continue the headcount increase. We're projected, as I just mentioned, to be essentially flat or slightly up for the fourth quarter. Only a slight labor increase cost during the fourth quarter, and our new guidance reflects all these things that I've talked about. Now, I wanna shift gears and talk a little bit about what we've talked about the last three years. We talked about these key transitions, and the transitions were all defined in an effort to create a higher growth and higher margin profile company that'll be more profitable for shareholders. The great news is, this is, I believe, the last call which I'm going to talk about in detail the transitions.
The reason for that is that I feel that over the course of this year, we have really worked through the transitions and the word transition implies some kind of, maybe exceptional operational risk or business risk. I feel we're through the exceptional period of risk on these transitions. In other words, each of the three transitions we've talked about has hit a milestone in my mind, where I'm comfortable saying, you know, there are business risks associated with the growth of these new product lines and undertakings by the company, these transitions, but they're no longer, existential risks, major risks to the company in the way that they might have been, say, 18 months ago when there were so many unknowns about these.
Let's look at each of those real quick and put them to bed so that we don't have to talk about them anymore. After Scotty presents the financials, I'm gonna spend a little time talking about the new go-forward paradigm of talking about the company instead of this older paradigm of explaining these three transitions. Let's look at them one at a time. The first, of course, was kind of proving the market acceptance of the new resuscitation suite program with the American Red Cross. The second was the establishment of a new functional area with the VerityStream SaaS-based application. As you remember, we had acquired several companies over the last several years, and we had launched a new set of applications for credentialing, privileging, and enrollment.
There's a lot of question we launched new products about the market acceptance, and I'm here to declare that the market has accepted the new VerityStream SaaS-based application we call CredentialStream. The third is the technical viability of our new platform architecture known as hStream. Here we go. Let's put all three of them to bed. The market acceptance of a new innovative resuscitation solution has been established as evidenced by our sales of American Red Cross Suite to customers in each of the 50 states of the United States of America. The program is established, the credential is accepted, the sales team are closing new business every week. You know, this concept that maybe the market wouldn't accept a second solution is gone now.
We've moved material market share to the American Red Cross, and we'll continue to sell that product in the coming years and months under a long-term partnership with American Red Cross, and we'll continue to innovate. It's no longer a question. The question we had two years ago was, will anybody buy it? Will anybody accept a credential, a professional credential from the American Red Cross? I guess I'm here to say today that that it's not only been accepted, it's been embraced, and the cutting-edge organizations are moving to this newer, more adaptable technology that we've introduced with the American Red Cross, and it continues to win new business in the market. I'm gonna put that transitional risk to bed.
The risk now is just how much can we sell, and then can we continue on a great trajectory with this partner? I think the answer to both of those is I'm excited. It's gonna be a great product into the future. The second, the product adoption of a market-leading SaaS-based credentialing, privileging, and enrollment application.
I think now with nearly 440 customers under contract, and many of them are implemented and live, and many of them are referenceable accounts, I think we've established that this newer platform we built, which was the best of breed from our four acquisitions, is both accepted as customers migrate to it from the legacy platforms and as new customers select it in open RFP bids and competitive bids, where I think we've built now the application set of choice in the industry as it relates to credentialing, privileging, and enrollment. Again, the risk was we acquired four companies, we built a new product and tried to move customers to, and it didn't succeed. I'm here to say that level of risk is behind us.
Of course, there's a normal market risk to competition and can we continue with this leadership position. With 440 contracts, customers migrating, and most importantly, the new RFPs being issued, we think we're gonna win a disproportionate share. If an organization of scale is bidding out privileging, enrollment, and credentialing services, we think our new CredentialStream platform is gonna win the day. The third is the technical viability.
We've been talking for quite some time now and hired a new CTO four years ago to lead the charge on building new technical infrastructure that will make all of our applications more interrelatable, make data more portable across our application offerings, and allow us to do really wonderful new service and application development as the platform gets established. I'm here today to declare that the platform is real, it's operational. We're releasing new functionality at the platform level, and that platform level capability is being extended into our application sets at an increasing rate. I think the concept of, well, you've been building in R&D, this underlying platform, will it be viable? I guess I'm here to say today that it is a viable platform and there's always more to build.
There's a great vision in front of us of what we wanna do with it. I believe we're well along our way to having both a new platform underneath HealthStream that unifies many of our capabilities and gives customers more reasons to acquire our applications and unifies us as a single platform company with multiple applications linking to it, and also makes our architecture more extensible to third parties. I'm here to declare, and I'll tell more detail about it, but the platform is real. We won't be talking about it as a transitional risk. We are selling in licenses. When someone acquires an application from HealthStream, we're embedding a license to the platform. Again, I'll talk more about what's exciting about that in a few minutes.
This concludes a nearly three-year journey of talking about the three transitional business risks. We can now start to talk about our new applications, the new markets we want to proceed with, and a new paradigm for talking about our company, which I'll cover after I turn it over to Scotty Roberts for a detailed look at the numbers. Scotty.
Yeah. Thanks, Bobby. I'm happy to report that we had another solid quarter of financial performance, and we're firmly on pace to achieve record annual revenues and Adjusted EBITDA for the year, both while overcoming a $38 million revenue headwind as we entered into the year. On a year-to-date basis, we've been able to grow revenues by 5% and grow Adjusted EBITDA by 15%. For the third quarter, revenues were $64.1 million, which is up 5% over last year and includes an $800,000 reduction associated with deferred revenue write-downs. Operating income was $1.8 million, down 43%. Net income was $1.5 million, also down 43%. EPS was $0.05 per diluted share, down from $0.08 per diluted share in the prior year.
Adjusted EBITDA improved to $12.5 million, which is up 11.5%. Workforce Solutions revenues were $51.2 million and were up 4%, and revenues from Provider Solutions were $12.9 million and were up 10.7%. On a consolidated basis, we grew revenues by 5% while overcoming a $9.2 million decline from the legacy resuscitation business. Revenues from recent acquisitions and growth in our core business more than offset this decline. When you exclude revenues from the legacy resuscitation business, consolidated revenues grew approximately 24%, which was comprised of 10.5% organic and 13.7% from acquisitions. Our gross margin performed as we expected, coming in at just under 65% for the quarter.
Our operating expenses, excluding cost of revenues, were up 15% or $5.3 million over last year. About two-thirds of this increase relates to the operating expenses from acquisitions that we completed primarily in the fourth quarter of last year. Our G&A expense during the quarter also includes a charge of about $350,000 related to closing several leased satellite offices that will expire next year. Our Adjusted EBITDA was $12.5 million, which is an increase of 11.5% over last year, and EBITDA margin was 19.5% compared to 18.4% last year. Our cash flows from operations improved to $36.4 million this year compared to $30.8 million last year.
DSO also improved to 40 days compared to 43 days last year, and free cash flows were $17.3 million versus $16.7 million last year. Our cash and investment balances increased by $5.4 million in the quarter and were $60.6 million at quarter end. Capital expenditures incurred were $5.6 million for the quarter and are up to $16.8 million year to date. After another strong quarter of financial performance, we have updated our financial guidance ranges as follows. We expect consolidated revenues to range between $255.5 million-$257.5 million, with workforce revenues forecasted to range between $205 million-$206.5 million, and provider revenues forecasted to range between $50.5 million-$51 million.
Adjusted EBITDA is now expected to range between $51 million-$53 million, and we expect capital expenditures to range between $25 million-$26 million. Our financial results continued to benefit from lower expenses than our previous guidance had anticipated. As was the case in the first half of the year, employee turnover remained higher than our normal experience, which we believe is consistent with employment trends facing most companies across the country. Although turnover has been higher than anticipated, we've been able to successfully fill open positions, but total head count has remained relatively flat over the course of the year, which has led to lower staffing levels and personnel costs than we had planned.
Sales performance was also steady during the quarter, but we started to experience some challenges related both to the resurgence of COVID and the impact of employee turnover that I just mentioned. Consistent with past experiences, the ongoing impact of COVID on our customers continues to cause some delays and uncertainty in their purchasing decisions with us, though it's not across the board. We have experienced longer sales cycles and delayed decisions from customers with high COVID patient admissions. We're also monitoring several other challenges our customers may be facing, such as vaccine mandates, nursing shortages, and overall staff turnover, which could impact their operations and their financial condition. As for the impact of employee turnover on our sales production, losing quota-carrying reps mid-year and onboarding new hires presents challenges to achieving our goals for the year.
Although as we enter our busiest sales quarter, our teams are focused on finishing the year strong. That concludes my comments for this morning. Thank you for your time. I look forward to providing updates on our full year 2021 results and guidance for 2022 on our next call. Bobby, I'll turn it back over to you.
Thank you, Scotty. It's kind of an exciting pivot point for me now. I've talked so long about transitions to all of you that have followed along our story, including our key analysts. Now I wanna kind of begin the orientation process to the future on how we're going to talk about the business as we go forward. Let's get oriented a little bit. The first is, over time, over a long period of time, we have talked a lot about a learning platform and a credentialing platform. I think inside our company and now to the outside world, we're going to communicate differently. We're going to correctly identify all of those as software applications or application suites. There's only gonna be one platform at HealthStream, it's hStream.
On a go-forward basis, let's think of HealthStream the company, as a one-platform company. hStream is the platform, and we have developed multiple sets of applications that run and ultimately, over time, will increasingly connect to and leverage the single platform. You'll see us correct ourselves often in the next year or two as we change from calling it the learning platform to the learning application set or the learning application suite or the learning application. The credentialing platform will become the credentialing application suite or the credentialing application and the scheduling applications. There'll be a shift, but it's important because it indicates the intent of why we're building hStream to underlie, interconnect, and interrelate all of the application sets that we offer.
We feel we've made enough progress now to make that declaration and begin to change our own internal language at HealthStream, and therefore, the way we talk about it with you. We'll have three primary application suites. They are learning and development. We have a whole suite of applications to help manage the learning and development processes at healthcare organizations. The second is credentialing and privileging. Again, it's a suite of products and a growing suite of products that includes products like credentialing, privileging, and enrollment, but it'll be known as credentialing and privileging application suite. Scheduling and capacity management. Some are newly acquired companies. We've talked a lot about the scheduling application area, and so the third area will be scheduling and capacity management.
In review, learning and development, credentialing and privileging, and scheduling and capacity management are the three different, at one point called them legs of the stool, but now I'll call them application suites. The reason we call them applications is because increasingly we expect them to connect to each other through the platform and connect to the platform and leverage platform-level services that were built into the new core hStream platform. We're excited to begin that transitional journey now in this important dialogue. Also many years ago, as you remember, we dropped a metric that we had where we measured the subscribers and subscriptions to the then learning platform, because we had new sets of applications that were growing, and we've begun reporting the number of subscriptions sold to hStream.
It's my expectation in the coming year or two that every application will sell with a license or a membership to the platform. We've begun that journey by bundling every sale of the learning architecture, the learning application, with an hStream license. We've begun that journey by selling every new CredentialStream sale within a subscription or a license to the hStream for VerityStream platform. It's very exciting that those two applications we feel are interconnected enough or reliant upon or providing enough value from the platform level that we can add and sell those subscriptions. We have been reporting subscriptions to hStream, and we added 402,000 hStream subscriptions in the third quarter, bringing our total to 4.92 million subscriptions.
This represents an increase of 29% over the same period last year, and the growth in subscriptions is encouraging. I wanna talk a little bit about the growing power of the hStream platform itself. Like, what is it going to enable us to do? I thought I'd walk you through an example, and so you can understand how it's evolving and what we hope to do with it. Remember, each of our applications already works well on its own. It's an independent application. With hStream, our applications are beginning to work even more powerfully together. One critical reason for this is our new identity management service we call the hStream ID. Again, it's part of the hStream platform, is the hStream ID.
Increasingly, the hStream ID allows data about an individual to be used across our various applications instead of remaining stuck inside of a single application. This new level of mobility and identity management adds value to the applications and also adds value to the data itself. If you think about all the time and expense our customers go through maintaining license data on their employees, for example, you can start to appreciate the value of the hStream ID. Thanks to the hStream platform, license data on an employee can now enter through the HLC, the learning application, be validated by a VerityStream application, and trigger our MyTeam application to inform managers when their employee's license is about to expire.
What you see here is by linking the identity of people in the various parts of our ecosystem on the different applications, we can provide a service, for example, of validating a license that only existed in one set of applications to where the data is maintained and stored in another application. The example I just gave, that portability creates kind of an interchangeable service of validating licenses using some of the features and functions of VerityStream and some of the distribution and access to the resultant data in the Learning Center application. In this example, the learning department, the compliance department, and the HR department all benefit from the hStream ID's ability to move an individual's license data across applications and enhance the quality and value of the data throughout the journey.
In the coming year, we look forward to providing additional updates about the growing power of hStream as our definitive platform. Now I'd like to provide some business updates regarding the three application suites. Let's start with learning and development, our most well-established application suite, and it's our oldest, but also, in many ways, some of our freshest things are coming out of learning and development, like the Jane platforms. In fact, the company's origins trace back to improving learning and development through technology, which is what these applications focus on today.
The past two years have been characterized by a great deal of innovation across this area, including the release of our patented AI-driven clinical competency application known as Jane, the establishment of a new industry standard in resuscitation certification with the American Red Cross Resuscitation Suite, and the combination of our KnowledgeQ and SafetyQ Solutions to form what we believe is the most dynamic governance risk and compliance solution in the market today. We're really excited about the continued evolution of the core applications and products of the learning and development area of our business. It's exciting to enter the next year with the innovations either in the market or entering the market as we speak. The Red Cross innovations are fantastic.
We created special technologies to empower the Red Cross program, like our interval technology, which allows organizations unprecedented level of flexibility in deploying the Red Cross resuscitation application and programming set. We've built platforms or applications like Jane that bring in the dimension of AI into the decision-making and critical review of critical thinking ability of nurses. We've updated what was once our core business in regulatory compliance to the new standard of microlearning and assessments and benchmarking services that can't exist anywhere else by definition because we have the largest network, over 2 million subscriptions to our legacy and now our newly refined compliance products and mandatory training products.
Really excited to have such a complete solution set that we think can have an impact across the governance risk and compliance areas of healthcare organizations across the country. I'd like to focus on two of our resuscitation offerings, maybe a little more detail about two of the products that are in this learning and development category of the American Red Cross Resuscitation Suite. We already mentioned that we've sold to healthcare facilities of all types and all sizes from across the continuum of care in all 50 states. Some of the industry's largest acute care healthcare systems and organizations have made wholesale switches to the American Red Cross Resuscitation Suite.
We think it's because of the combination of the technologies HealthStream has built to enable flexibility in the program and the incredible investment and high clinical quality of the program itself built and credentialed by the American Red Cross. It's the combination of our platform and our applications with their content and certification that's resulted in this industry-changing program. In fact, since as of September 30th, we have over 340,000 certifications have been delivered through the platform. Remember, we just began selling this 24 months ago, and it took time to implement and switch customers over. Now the rate of completions of this Red Cross program is really quite staggering, and we've just passed the 340,000 certifications delivered.
Again, with the rate of consumption is just fantastic. That's gonna continue to climb very rapidly. What's fascinating too is that the solution required that we deploy over 7,000 new high-tech internet-connected mannequins by a company called Innosonian, the Brayden Pro Mannequins. What's great about those mannequins is that they're modern, they provide visual feedback to the user, they're internet-connected, and they use the hStream ID. We mentioned earlier about the power of the hStream ID. The data collected through those applications and those mannequins that is kind of skills reporting data on the employees goes into the hStream cloud services and becomes mobile and portable in that way.
Anytime someone anywhere in the world logs into the app that connects to that Brayden Pro Mannequin by Innosonian, they're logging in with the hStream ID, which creates this portable record on the individual. We're really excited about both the new technology, like the Innosonian Brayden Pro Mannequins, of which there are now 7,000 deployed across the globe, and how they utilize the hStream platform to give them a new power and flexibility. I believe it's just remarkable that an option that didn't exist two years ago has gained such widespread adoption. That's a testament to the strength of our sales organization, the innovations of the Red Cross, and the innovations of our technical teams to build this market-leading product. From a technical standpoint, it's just outstanding.
In fact, our score is four out of five stars from our own customers on the implementation process to the change management process to this new application. We're focused on the operations, the quality of the transition, and our customers are giving us 4.8 out of five stars during the third quarter on the quality of those transition services. Great job by our teams that are focused on that solution. Let's shift gears and give an update on the credentialing and privileging. Three years ago, we announced the launch of VerityStream, and at the time, that was our new SaaS-based application for managing the full spectrum of credentialing, privileging, enrollment needs in healthcare organizations.
During the third quarter of 2021, 47 customer accounts contracted for CredentialStream, the new platform. 47. I believe in the second quarter it was around 42, and in the first quarter around 45, maybe 46. Really, the adoption rate is quite staggering of the new CredentialStream platform. We're really excited about its progress. Now, the implementation cycles on this product, it's more complex than, say, some of our other application sets, so it takes longer to get to revenue. There's a bit of a, what I'll call an air gap or a bubble from the selling that was imposed by COVID to the implementing.
We'll see a little bit more growth coming out of all those sales in the second half of next year and a little bit of what I'll call these air gap bubbles, where, you know, we made a lot of sales, and then there's a delay in implementing. The implementation cycle is already fairly long on that product, say up to 12 months. We're gonna see some of the impacts of COVID in the growth rates the next few quarters. The sales have gone unabated, which is fantastic. It's gonna take us a little longer to get to the revenue. I would expect to see some of the growth from all those sales just really start showing up.
Again, it's we did a nice growth rate in this third quarter on VerityStream and, but I think what we'll see is even a better growth rate in the second half of next year. That's really exciting. I wanted to give you the context for how and why. 47 new, we call them new logos, new customer accounts contracted for that CredentialStream application in just 90 days. It's really fantastic, the sales rate that's happening there and the new wins. Some of the wins include well-known organizations like Hackensack Meridian Health, Main Line Health, MedStar Health system up in Washington, D.C., Cooper University Health Care. They're just a few of the exciting organizations that are realizing that we have a best-in-class solution for credentialing, privileging, and enrollment.
Now, this third application set that we wanna talk about is scheduling. Just as we acquired four standalone companies in credentialing and privileging, and we built a new solution, we plan to use that playbook and do it again in scheduling. Our acquired organizations, NurseGrid, in the last nine months, ShiftWizard and ANSOS, all happened in the last, say, 12 or so months. We're assembling that into a leadership team with a vision to build a market-leading scheduling system. We believe we have some innovations in store for the industry that will help make that vision become reality. We're early in the journey to building this part of the business out, this application suite. We're early in the journey, so we don't wanna get ahead of ourselves.
We've got a lot of R&D to do, but we're getting a clearer roadmap, and I want to share some of that with you. The transition and integration of the businesses themselves, the operations of HealthStream, is nearing completion. The transition services agreements from the parent companies we acquired them from are winding down, which means we've shifted all the reliance to our own servers and our own capacity. The basic business integrations are done, and the organization itself is beginning to grow and assemble the leadership team. A lot of progress on the business front. On the software front, we've now internally published our kind of our vision and roadmap and our tenets for success, where we're going to begin building and testing the hypothesis that we thought were strategic advantages in the first place.
It's great because we have over 380 customers to work with. Through the acquired companies, we inherited about 380 customers, along with some new ones we won this year. We plan to show those 380 customers under contract a lot of innovation in the coming 12 months, where we'll be doing exciting things like connecting some of the best-in-class capabilities of the NurseGrid mobile experience into the customers of the ANSOS and ShiftWizard platform. Can't wait to show more about that, but we're making great progress. We've been working on those integrations for a while, and I think the first wave of innovation out of our scheduling and capacity management business will come as we announce the connectivity of the NurseGrid application to both ANSOS and ShiftWizard in the coming months.
Now what's really exciting about that is the nature of those products is a little different. The NurseGrid application is actually a B2C app available in the Apple App Store. We thought that it's this kind of growing community of nurses that love this app, which blends their social personal life schedule with their work schedule. We just thought there was something special about how that was happening. In fact, we've seen NurseGrid Community continue to grow since we acquired it, and now we're up to nearly 350,000 monthly active users. That's up 90,000 active users or 35% since our acquisition in March 2020. That application has continued to grow in its adoption. Remember, that's elective adoption.
That's a nurse going into the Apple App Store, downloading the app, and using it on at least a monthly basis, 350,000 MAUs, monthly active users. 46% of those nurses log in every day. That's up 40% from the time of acquisition, which means they use NurseGrid often and consider it to be a valuable resource for managing their personal and professional schedule. NurseGrid continues to be the number one rated app for nurses in the Apple App Store. That's a 4.9 star rating with 70,000 reviews. That's up 40,000 reviews from the time of acquisition. This growing network of nurses that blends their social and personal calendar with their work calendar, we think is something special.
We think that network, that growing network now of 350,000 monthly active users, as it's linked into the business applications that manage scheduling from the business side, is gonna be a powerful, competitive, advantage. In fact, we have a vision for how it can enhance the functionality that we'll be sharing in the coming months as we release that functionality. During the third quarter, some final updates here. Some events are happening across the company, and then we'll wrap it up for questions because I know I've gone long, but this is an important transition call, so I wanted to spend some time on it. There are two kinds of events that we wanna talk about so our employees can hear and customers can celebrate. During the third quarter, we hosted our second annual Nurse Wellbeing Week.
This amazing virtual event was held September 27th through October first, and it's a week of engaging activities on the topic of nurse wellbeing. It's kind of our service back to industry to recognize, all that our nurses across the country have been through. Over 6,500 nurses registered for the Nurse Wellbeing Week activities that were focused on practical advice from peers and experts on enhancing wellbeing, speakers and activities and sessions. It's part of giving back at HealthStream, very successful and focused on the wellbeing of nurses, just a way to engage, our future customers and current customers and the nurses that are serving our country so well through this, effort we call Nurse Wellbeing Week. Thank you to the teams that ran it.
VerityStream customers will also be participating in a virtual two-day users group conference called Thrive 2021. The event will be on November second and third, include keynote presentations and full track sessions for each VerityStream application, including the core CredentialStream that we've been talking about. This is an exciting conference where we often release data from our proprietary market research about the credentialing industry overall and the trends in it. Thrive 2021 right around the corner, November second and third for the customers of VerityStream, HealthStream's VerityStream. Finally, I couldn't miss the opportunity to shout out National Customer Service Week. We have over 100 employees in HealthStream focused on customer service of our over 1,060 or so employees.
Those employees differentiate our company every day by the way they manage our customer relations. I'm really proud of how they handle them, and our customers love the service they get from HealthStream. We'll continue to improve our service continuously and innovate how we service the customers. On National Customer Service Week, the first full week of October, it gives me a chance to say thank you to the nearly 100 employees that are customer-facing, that really try to do everything they can to get rapid response done and high marks for quality, both of which they're achieving on a daily basis. Thank you to our customer service personnel across HealthStream. They serve as the face of HealthStream, and we're grateful for the work that they do to build customer relations.
You know, I don't think you can sell another application to a customer unless they're satisfied with the service they get, and I think our teams are best in class and best in the country at taking care of people quickly and giving them the answers they need. At this time, I'd like to turn it over to the analyst for questions.
The question and answer session will begin at this time. If you're using a speakerphone, please pick up the handset before pressing any numbers. Should you have a question, please press star then one on your push-button telephone. If you wish to withdraw your question, please press star two. Your questions will be taken in order that they are received. Please stand by for your first question. Our first question will come from the line of Ryan Daniels from William Blair. You may begin.
Hey, guys. This is Jack Senft on for Ryan Daniels. First off, congrats on the quarter, and thank you for taking my question. I guess maybe if you can provide just a broader update on the health of your client base? You know, I guess we've seen some early data points from publicly traded hospitals that suggest ED volumes are coming back. I know in your prepared remarks you did touch on the pandemic and seeing it subside a bit and possibly translating into potential ED volume returns. Just kind of curious if that's something you're seeing broadly and any other color you can share amongst the client base? Thanks.
Sure. In certain areas of our client base, so it's kind of been regional impact. I'd say their operations through the different waves of COVID have been interrupted, which kind of put I've now referred to them as little air gaps. If you sold a system and you wanted to begin implementation in a certain part of the country, they may have delayed implementation for 30, 60 days as they work through capacity issues and staffing issues, and then they get it back on. It kind of put all these little air bubbles into our business with them. That said, they keep resurging. In other words, they learn to manage the new norm fairly quickly.
I see that they're more adaptable in how they've managed the Delta variant surge more responsive. The good news is there are more treatments out. I think the executives I talk to that run the big health systems have a little more confidence in their ability to handle the pandemic. Maybe as you hear now the dialogue of moving towards an endemic situation for the pandemic. That's my observation is that particularly in the bigger systems, too, they're learning to operate in a mode that will let them be successful now. They do face unprecedented, and I hear this over and over, challenges with their workforce. We talked about the Great Resignation impact on HealthStream, but in hospitals and nursing, it's incredible.
The mobility of nurses, they're reevaluating their lives. They've been through a lot of hard work. They're both resigning and changing careers. The executives I talk to talk about the need to find ways to retain, develop. We even see some large health systems acquiring nursing schools because they know they have to get into really talent development and retention and growth. I think that does bode well for our positioning in the future. Needless to say, it's a current challenge. It's tremendous. It has both financial implications. If you're a smaller organization, how do you recruit, retain, and pay competitively? If you're a large one, how do you reduce your reliance on contingency labor pools, which are just too expensive?
I think over time, in the three-year window, result in more health systems being more involved in the development of their own workforces, more than they ever have in the past, which is a positive. In the short run, cost pressures and turnover issues on quality are all gonna be real. Generally, I see recovery and with a few remaining pockets that are still dealing with the issues I talked about.
Perfect. Thank you. Just kind of a quick follow-up, and I know you just talked about a little bit of the burnout and staffing issues and stuff. If you could touch on a little bit how HealthStream is kinda helping the providers deal with these issues, you know, and if you can provide any additional color on the labor market pressures, you know, that would be really appreciated. Thanks.
Sure. Well, I think the trend I just noted was it's kind of a belief rather than maybe a current reality. I do see and I've seen some of the market-leading larger organizations begin to address the issue of their workforce by doing things like I mentioned, like buying a nursing school. To me, that's a symbol of the willingness of the market leaders to invest in the future of their workforce. Of course, that bodes well for us because we're all about the retaining, developing, credentialing and support that workforce to be more successful in their role. I would just say that they'll need to awaken to the need, to the extent that they haven't already, to invest in their workforce. It doesn't mean just education.
It means all things related to the benefits, flexibility. There's a cost, but also in the outright training and development of their skills and development of their career path. You know, career paths for nurses have been fairly flat over time. You kind of become a nurse, and you're a nurse your whole life. It's unlike business where you become maybe a Director, a Senior Director, an AVP, a VP. I think the organization will need to find new ways of recognizing skill, promotion, and differentiating quality and good decision-making by their staff, and then that resulting in better pay models and paying the talented people more.
All of that bodes well for HealthStream as we help distinguish the high-quality nurses that are able to think on their feet and get better patient outcomes. We're able to identify gaps with our Jane technology and their skills and their thinking processes, and then remediate them with intelligent AI-driven recommendations. I think we're well positioned for the future as organizations wake up to the need to invest in their workforce. The shortages are acute.
You know, we've seen a boom in the travel nurse industry because the inability to retain and attract will keep full staff. The staff bed counts have gone down, and only the largest organizations are able to kind of keep everything running the way they want to. There's a lot of staffing issues that they have to work through, and mainly they're gonna see price inflation for their staff in the coming year if they don't find ways to develop their own staff and retain them.
Perfect. Thank you. I'll jump back in the queue.
Our next question will come from the line of Matthew Hewitt from Craig-Hallum. You may begin.
Good morning, and thank you for the broad-based update this morning. My first question relates to your employees, some of the challenges that you've been finding. Now that you've moved to more of a hybrid model or in many cases maybe even just a fully remote with occasional travel to meet up as a team, is that allowing you to recruit nationally? If so, what types of barriers or challenges does that present?
It was a culture where we got together a lot and of course, worked out of offices almost, you know, we were a majority focused in the office, and we spent a lot of money and time through our teams to celebrate successes, recognize peers, onboard new employees in a face-to-face setting. Of course, the last 16 or more months that we haven't done that. What we're kind of declaring while we've closed leases, we've gone from like 11 leases, we'll be down to like three or four here soon. We're doubling down on the big resource centers in San Diego, Boulder, and Nashville, which are well-positioned across the country to convene employees. The cost of convening, let's say each division gets their division together for a three-day retreat now annually.
We didn't do that before, but we want everybody to come in and centered around one of our resource centers, have a three-day retreat where they'd recognize new employees, give awards to those that may hit milestones, onboarding new employees, do a day of strategic planning, and the cost for that will be higher. Like, it's like a national sales meeting several times a year for each division as we think differently about convening. But I think it's essential to do investments like that to maintain our culture. Our culture is what's attracted the talent to our company. We have experienced higher turnover, departures.
I just think that people who've been somewhere for four or five years or more, they put their head up and thought maybe they wanted a life change, and they look out to try to see if they can find greener grass. Even if you're part of a great company, I think there are variables that are beyond just even if you love your colleagues and peers, and we hear that a lot, and someone says, "Well, I just wanted to go try something different." love HealthStream, love the colleagues. The great news there is I've seen a couple come back already, and they kind of went astray, in my view, and have decided to come back. I think the turnover will settle out.
I think we'll be positioned to be in a better position than other companies as it does. As I mentioned in the call earlier, we continue to hire at an incredible rate. As people are leaving, we have excited people who wanna join our vision because they think healthcare is a great place to serve humanity and kinda live out a personal life mission along with a work life mission. We've attracted great new talent. The net effect of all that has been a fairly flat head count. You know, one of the reasons for our financial outperformance is because of that. We had expected to add a net of over 100 employees throughout the course of the year. We've been unable to do that. We've kinda hired one and a half, lost one.
You know, I hope that the turnover reduces so that the new hires take hold, and we can get our staffing levels up a little higher. But I think we've determined at this point, three quarters in, that we're not gonna catch up in our numbers this year. We'll just maybe look to slow down the turnover rates as we enter next year and continue the hiring and have some people start to return to HealthStream, which I do fully expect, and get out of this loop of the Great Resignation.
Understood. Thank you for that color. Maybe one other one. An additional question here, and not trying to nitpick, obviously, it was overall a very good quarter. Workforce Solutions was down sequentially. Was there anything that hit in Q2 that was maybe more one-time in nature that we didn't see recur here in Q3? Or what kind of drove that? Albeit very small, but just normally used to seeing sequentially up. We're used to seeing sequentially up for Workforce.
I'll let Scotty.
I'll comment on that for you. I think in the maybe the last call, I alluded to a couple one-time items that were benefiting our revenues in the first half of the year. We saw less of that benefit in the third quarter. I think you know each quarter we saw a little bit of that occur, but just less of an impact in Q3 than we had in Q1 and Q2. Mainly that's the legacy resuscitation that continues to dwindle down. The second one is just some one-time software or perpetual license sales benefited from some of those in Q2 and Q1, but less of that in Q3. Those are primarily the two driving forces behind the sequential decline that you saw.
Got it. All right. Thank you very much, and keep up the good work. Thanks.
Our next question comes from the line of Richard Close from Canaccord. You may begin.
Yeah, thank you. Scotty, can you go over the acquired and organic percentages again? Just for clarity, that was total revenue that you gave it for?
Yeah, Richard, I think I spoke about consolidated revenue growth once you back out the impact of the legacy resuscitation losses. Let me get to the number real quick, and I'll repeat it for you. I think it was 10.5% total, that was organic, and then I think 13.7% from acquisitions. So roughly 24% thereabout in total.
Okay. Schedule wins all in Workforce, right? Correct? Is that?
Yeah. That's where it is.
Okay. Great. Thanks for that clarification there. Bobby, maybe with respect to turnover, could you give sort of maybe characteristics of the individuals that are leaving in terms of, is it any one department, like sales, product development, you know, whatnot? And then, like, the experience level, are these, like, long-tenured HealthStreamers, or, you know, have they been there a short period of time? Anything along those lines?
Sure. I would say in our group of what I guess I would call our AVPs, VPs, and senior VPs, so the top 50 employees, extremely low. Like, I think the one that I can identify has just indicated a desire to come back to the company. That's the good news there on the leadership front. Now, maybe leaders take longer to reevaluate opportunities and decide to leave, so I don't wanna say that that's a done deal, that we've kept all of our leaders. That is the fact currently right now in the leadership group. It's very low. As I mentioned, the one that I can think of that left is indicating a dialogue to come back already, so, which is fascinating.
Sans that's 50 of a 1,000 and 60 employees. The other 1,000 employees, I would say it's just across the board. It's turnover in the new employees that came in for a few months and wanna try something different. I don't know. They're just maybe a more mobile, younger workforce. It's some of the veterans. It's in all departments. You'll see it, like if one person gets recruited away to work somewhere in a department, then maybe they that recruiter and that team comes back in and grabs a few more from that department. Sometimes this results from a pay raise or a rumor that it's gonna be a better, more flexible job.
I think it's just kind of broad-based, and it's a result of people reevaluating their work life and deciding to try something new. I can't identify any single area, but I would say it's kind of equally high in all areas, from sales to operations and across all experience levels. It will introduce a challenge, right, when you have that much change at all those levels of experience. Now what it's resulting in, though, is a lot of internal promotions, which is exciting. People are willing to stay with us or assuming new roles. Like if there are five project managers and one of them leaves, then there might be a new team lead out of the four that remain, and then we backfill and hire a new project lead.
Tremendous amount of promotion coming out of our service groups as we promote someone who's been three to five years in our customer service areas into operations support. There's upward mobility that's resulting and new employees coming in, but there's also that outflow and it's balanced, Richard. I'd have to say, you know, it's hitting every operations function of the business and kind of in little waves, like a couple sales people leave and a couple operations people leave. It's just balanced.
If I could just slip in another housekeeping just for clarification. The 47 customers on credentialing, are those totally new credentialing customers, or does that also include the conversion of the legacy?
It's both.
Okay.
I think the ratio is about half and half. It's those that are upgrading, too, and those that are brand new, too. I may correct it. I'm gonna watch my text from some of my officers you may send, but hopefully you still listen, although this call is long. I think it's split across the two, the 47. They're new to the CredentialStream platform, but some are migrating. I may get corrected on that in the next few seconds, but if not, we'll stay with that answer.
Okay. Thank you. Have a good day.
Thank you.
Our next question comes from the line of Vincent Colicchio from Barrington Research. You may begin.
Yeah, Bobby, a follow-up on the last question. Is the transition to the VerityStream from existing clients, did that meet your expectations in the quarter?
Hang on. I'm texting an officer to get a better answer. Yes, they exceed expectations. I think a couple of things we've learned is that as long as the customers stay on the older platforms until they're ready to migrate, there's not a huge cost benefit to the migration. We're really happy if they stay happy and they migrate when they're ready to. There's no forced conversions here. These are elective when they see enough features to move. What I would say is we're seeing a material number of them decide that there's enough reason to move to choose to move, and I'm excited about that.
Of course, the new accounts that we're winning are fantastic because they are in RFPs, and we're competing, and we're winning a disproportionate share of the open bids. We're really excited to see that trend. Both of those trends are encouraging. We're not forcing transitions, but we're getting them and we're winning in the open market.
On the labor side, does the company continue to see moderate wage inflation?
So far, it has not been tremendous wage inflation. In other words, we've been able to promote internally to fill a position loss. Someone may get a raise because they moved from a team participant to a team lead if a team leader leaves the company. Overall, we've been able to reasonably fill the open positions at the similar salary bands previously, which is ironic. At some point, we're gonna see wage inflation 'cause people that are leaving are leaving to get a promotion or market themselves into a maybe a better, higher paying job with more responsibility. If we bring them back, they'll come back in and be more expensive. Right now, on the whole, I'd say we're filling at only slight increases in the total net cost.
Okay. That's it for me. Thanks.
I think that's because of our approach to promoting from within. As a manager leaves, we're often able to pick someone to promote into the manager position then backfill the less experienced position with a new person. I think that upward mobility has helped us a lot in kind of maintaining our cost structure. What it means, though, is you got to do a lot more hiring at the entry-level, and you have to rely on the entry-level. One thing that might be happening a bit is we as we drain the entry-level pool, in other words, if you've been in customer service for two years and you're eligible for a promotion to a manager, and we've tapped all those people, it gets harder to fill the experience level at the same cost. Does that make sense? And so, uh-
Yes.
Our first wave, we've been able to maintain flat costs, but I do expect things to maybe start to creep up on us in the next year. A quick update on the question that Richard Close asked. 47, 31 of them were new customers and 16 were migrations. 2/3 of the 47 were new, brand new accounts to HealthStream on the CredentialStream platform, and 16 of them were migrations.
That's it for me. Thank you.
Thanks, Matt.
Thank you. Now I turn it over to Robert A. Frist Jr. for any closing remarks since we don't have any more questions in the queue.
Well, I imagine we scared off the questions by going for an hour. I appreciate anybody that stuck it out this long. Hopefully, the detail was informative. We look forward to putting the transitions behind us and speaking to the three application sets and the single platform company we're becoming and the SaaS architecture we're deploying. Couldn't be more excited. Thank you all for participating. Look forward to the next earnings call.
This will conclude today's conference call. You may now disconnect. Have a good day.