Health Tech

Bluesky Ahead


I’ve been thinking about writing about Bluesky ever since I heard about the Jack Dorsey-backed Twitter alternative, and decided it is finally time, for two reasons. The first is that I’ve been seeing so many other people writing about it, so I’m getting FOMO.  The second is that I checked out Nostr, another Jack Dorsey-backed Twitter alternative, and there’s no way I’m trying to write about that (case in point: Jack’s Nostr username is: npub1sg6plzptd64u62a878hep2kev88swjh3tw00gjsfl8f237lmu63q0uf63m.  Seriously).

It’s not that I’ve come to hate Twitter, although Elon Musk is making it harder to like it, as it is that our general dissatisfaction with existing social media platforms makes it a good time to look at alternatives.  I’ve written about Mastodon and BeReal, for example, but Bluesky has some features that may make sense in the Web3 world that we may be moving into. 

And, of course, I’m looking for any lessons for healthcare.

Bluesky describes itself as a “social internet.”  It started as a Twitter project in December 2019, with the aim “to develop an open and decentralized standard for social media.”   At the time, the ostensible goal was that Twitter would be a client of the standard, but events happened, Jack Dorsey left Twitter, Elon Musk bought it, and Bluesky became an independent LLC.  It rolled out an invite-only, “private beta” for iOS (Apple) users in March 2023, followed by an Android version in mid-April (again, invite-only).  People can sign up to be on the waitlist.  There are supposedly over 40,000 current users, with some million people reportedly on the waitlist.

By all accounts, it is similar to Twitter in many ways.  You can search for and follow other users, you can create posts (please don’t call them “skeets”) of 256 characters, you can attach (some types of) media, and you get a feed of suggested posts from other users.  You can like, reply to, or reshare posts.  It doesn’t yet have all of Twitter’s features, such as DMs or hashtags. It is working on “composable moderation.”

The point isn’t how much it looks and acts like Twitter but how different the underlying platform is.  It is built on what is called the AT Protocol – Authenticated Transfer Protocol. A blog post last fall explained what makes it unique:

Account portability. A person’s online identity should not be owned by corporations with no accountability to their users. With the AT Protocol, you can move your account from one provider to another without losing any of your data or social graph.

Algorithmic choice. Algorithms dictate what we see and who we can reach. We must have control over our algorithms if we’re going to trust in our online spaces. The AT Protocol includes an open algorithms mode so users have more control over their experience.

Interoperation. The world needs a diverse market of connected services to ensure healthy competition. Interoperation needs to feel like second nature to the Web. The AT Protocol includes a schema-based interoperation framework called Lexicon to help solve coordination challenges.

Performance. A lot of novel protocols throw performance out of the window, resulting in long loading times before you can see your timeline. We don’t see performance as optional, so we’ve made it a priority to build for fast loading at large scales.

There’s a lot to unpack there – more than I’m qualified to do – but here are a couple of key takeaways.  Currently, you don’t have much, if any control, over your Twitter feed (or your other social media feeds); the platform algorithms dictate.  Bluesky promises that the AT Protocol will allow users to both know what algorithm is being used and to choose from a library of algorithms.  How users will understand the consequences of different choices is not clear.

CEO Jay Graber says

Our goal isn’t to create every algorithm in-house, but to enable the developer community to bring new algorithms to users swiftly and effortlessly…We want a future where you control what you see on social media. We aim to replace the conventional “master algorithm,” controlled by a single company, with an open and diverse “marketplace of algorithms.

Equally important, Bluesky’s goal is that you could port your Bluesky experience – your list of followers, your historical feed, etc. – to other platforms (presumably that are also built on the AT Protocol).  It would tear down the “walled gardens” that have been recreated with existing social media platforms.

Kade Garrett, writing in Decrypt, points out: “In essence, the AT protocol would enable the creation of not a single social network, but a federation of social networks that could interact with each other…At a technical level, this would allow you to self-host the servers of your own company, profile, or social media platform.”  

As Bluesky tweeted: “We can switch mobile carriers without losing our phone numbers. If we could switch between social apps without losing our identity or social graph, then social media would be a competitive open market again.”  It sees switching platforms are more akin to changing mobile phone providers – keeping the same number – than switching email providers, which requires a new email address.

All this is based on what Bluesky refers to as “self-authenticating protocol,” which moves authority to authenticate from the host to the user.   But I’m going to leave the explanation of how that works as an exercise for the interested reader.  Mr. Garrett explains the importance of this: “The goal of such a design is to secure user data and make the user platform experience resistant to influence from corporations, governments, and other centralized entities.”

Who wouldn’t prefer that?


Social media is a mess.  Most platforms have been built on the you-are-the-product approach that has done untold damage to our privacy and to the level of our discourse. The kind of platform Bluesky seeks to be holds lots of appeal – although whether it can work, much less make a viable business, remains to be seen.

Healthcare has been a mess even longer than social media. Sure, it pays lips service to our privacy, but has failed to protect it (e.g., hospitals), and is only belatedly recognizing types of the loopholes it has (e.g., health trackers). We’re all subject to more algorithms than we realize (e.g., prior authorizations), and AI is going to exponentially increase that. It talks up interoperability and now has FHIR and TEFCA, but if you think you are now in control of your data, you’re misguided.

I don’t know how, or even if, the AT Protocol could be used in healthcare, but healthcare sure needs something like it.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented, and now regular THCB contributor