Emoji for the Medical Community—Challenges and Opportunities | Humanities | JAMA | JAMA Network
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The Arts and Medicine
September 7, 2021

Emoji for the Medical Community—Challenges and Opportunities

Author Affiliations
  • 1Division of Psychology and Language Sciences, University College of London, London, UK
  • 2Emojination and Unicode Consortium, Mountain View, California
  • 3Department of Emergency Medicine, Massachusetts General Hospital, Boston
  • 4Lab of Computer Science, Department of Internal Medicine, Center for Innovation in Digital Healthcare, Massachusetts General Hospital, Boston
  • 5Harvard Medical School, Boston, Massachusetts
JAMA. 2021;326(9):795-796. doi:10.1001/jama.2021.8409

In 2010 emoji were officially introduced to the global lexicon as part of Unicode, the computing standards adhered to by most of the world's word processing systems. Today an emoji occupies the same status in Unicode as the Latin letter A, or Chinese character 愛, or Arabic غ, and an estimated 5 billion are used every day on Facebook and in Facebook Messenger alone.1 Emoji set curation is overseen by Unicode Consortium, a Silicon Valley–based nonprofit tasked with maintaining text standards across computers, whose members include representatives from Microsoft, Apple, and Google, among others. Anyone can propose new emoji, but each submission is reviewed via a formal and lengthy consortium process.

As of 2020 there were 3521 emoji in the Unicode Standard, roughly 30 of which could be considered relevant to medicine, excluding generic body part images (eg, ear 👂, hand 🖐, leg 🦵, and foot 🦶). The current set of medical emoji is the result of ongoing, if erratic, efforts over the last 5 years. The first, introduced in 2015, were syringe 💉 and pill 💊. In 2016, efforts to expand the representation of professions brought male health worker 👨 and female health worker 👩. In 2017 Apple added emoji to better represent individuals with disabilities, collaborating with the American Council of the Blind, the Cerebral Palsy Foundation, and the National Association of the Deaf to introduce the white cane 🦯, mechanical arm 🦾, mechanical leg 🦿, and hearing aid 🦻 emoji, among others. Stethoscope 🩺, blood drop 🩸, bone 🦴, tooth 🦷, and microbe 🦠 (often used to represent viruses) followed in 2019. In 2020, 2 of the authors (D. L. and S. H.) worked with a member of the UK’s National Health Service (NHS) to win Unicode approval of the anatomical heart and anatomical lung (Figure 1).

Figure 1.  Sample of Existing Medical and Health Care Emoji
Sample of Existing Medical and Health Care Emoji

In 2020, these authors also proposed an additional 15 emoji: intestines, leg cast, stomach, spine, liver, kidney, pill pack, blood bag, IV bag, CT scan, weight scale, pill box, ECG, crutches, and white blood cell (Figure 2).

Figure 2.  Medical Emoji Proposed to the Unicode Consortium, 2020
Medical Emoji Proposed to the Unicode Consortium, 2020

The medical field would benefit in significant ways from representation by a more comprehensive and cohesive set of emoji. We are actively curating such a set. The next step is for the medical community to better leverage these hard-won emoji. But how? And why?

It’s tempting to dismiss emoji as a millennial fad, the “textual equivalent of an adolescent grunt.”2 But as a preloaded, curated, digital set of images that work across platforms—mobile, tablet, desktop; Windows, Apple iOS, or Android—emoji possess the power of standardization, universality, and familiarity to users, with increasing usage in both informal and professional settings. Emoji can facilitate communication of patient symptoms and concerns or other clinically relevant information, can be used as annotations for patient instructions, and more.

As one example, written discharge instructions may be incomprehensible to many patients, who may be uncertain of the reason for their hospitalization or unable to describe their diagnosis,3 and preliminary evidence indicates patients, particularly those with lower health literacy, may prefer reported outcome data in emoji format, and that emoji may promote comprehension.4 Especially when rapid communication is key, such as in emergency medicine settings, the ability to rely on a point-and-tap form of communication may at least be useful and could facilitate important clinical decisions. Emoji may also be a valuable tool for navigating language or verbal challenges, such as when treating children with still-developing language skills, people affected by disabilities that inhibit their ability to communicate, and patients who speak a different language. In the commercial research space, visual scales such as the Smiley face Likert scale already have a history of use in pediatric settings to accommodate children who are not yet literate and to make communication easier for those who are.5

Pictorial representations such as visual analog scales (VAS) are already used in medicine to measure and communicate the intensity or frequency of symptoms.6 It is well-documented that pain, particularly postoperative pain, is not treated appropriately, especially in acute settings such as the emergency department, when patients are often in distressing situations, and also in pediatric settings, since children experience pain in the same way as adults but it may be exaggerated by fear, anxiety, coping style, and lack of social support.7 The Wong-Baker FACES Pain Rating Scale has helped children effectively communicate about their pain since 1983, by showing a series of faces ranging from a happy face at 0 or “no hurt,” to a crying face at 10, which represents “hurts like the worst pain imaginable.” Yet these VAS are trademarked and come with licensing fees. Emoji that are open source and nonproprietary present an alternative that is not cost prohibitive, increasingly more familiar to patients, and digitally accessible.

This last benefit has been underscored by COVID-19 and its acceleration of telemedicine as a potential solution during times of disaster and public health emergency.8 Both the Centers for Disease Control and Prevention and US Department of Health and Human Services have recommended telemedicine as a means of providing care safely to patients during the pandemic. More broadly, telemedicine’s steady growth in the last 2 decades underscores the opportunity for the medical community to adapt to an increasingly digital world. Health care workers communicating with patients via online messages may be able to use emoji to convey symptoms and help patients understand their condition and instructions via recognition rather than recall. And the examples mentioned here are not exhaustive; many more opportunities exist for emoji to be leveraged in health care settings, as part of displays in mobile health applications, patient handouts, or visual communication aids.

It is important to note that emoji complement traditional modes of communication but carry their own constraints. While textual languages come with linguistic barriers, digital communication is susceptible to the digital divide that precludes those with less access to technology, especially older patients. Particularly since the pandemic, many clinicians have encountered patients using telehealth for the first time, whose familiarity with technology is not as facile as others. In addition, patients may have varying levels of familiarity with human anatomy to be conversant in medical emoji. Health care workers themselves may need to overcome certain barriers; studies have found that 72% of health care workers that now integrate emoji in their work were initially hesitant.9

It is clear that emoji will be a part of global, mainstream dialogue for the foreseeable future. With medical emoji still in their infancy there is a window of opportunity for the clinical community to proactively shape the way this method of communication is incorporated into medical practice and research. Moreover, given that the Unicode Consortium is a standards-setting organization, it responds best to industry consensus and standards that it can import and rely on. A medical example of this standard friendliness is the incorporation of emoji skin tones, which are based on the Fitzpatrick skin classification system, originally developed in 1975 as a way to assess how different skin types respond to UV light, but now a part of emoji keyboards around the world.

The medical community should begin to work toward consensus on what iconography would best serve patients and the profession with the goal of improving the accessibility and quality of health care and health information in the digital age. Medical practitioners, researchers, and staff can take the lead by formalizing a unified perspective on emoji relevant to the field, including important gaps and solutions. Physician organization committees tasked with managing the submission of and advocacy for medical emoji would fill a current vacuum, where there is no formal process for proposing and evaluating medical emoji. Such a dedicated effort would enable diverse medical practitioners to participate in the process and influence the evolution of a clinically and demographically representative set of images for widespread use.

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Article Information

Corresponding Author: Shuhan He, MD, Department of Emergency Medicine, 55 Fruit St, Boston, MA 02114 (she@mgh.harvard.edu).

Conflict of Interest Disclosures: Ms Lee reported being the founder and unpaid volunteer of Emojination. No other disclosures were reported.

References
1.
Buchholz  K. The history of the 5 billion emoji used every single day. World Economic Forum. September 30, 2020. Accessed March 14, 2021. https://www.weforum.org/agenda/2020/09/emoji-numbers-facts-social-media-how-many-twitter-facebook-instagram
2.
Evans  V. Breaking the emoji code. LinkedIn. March 2020. Accessed April 2021. https://www.linkedin.com/pulse/breaking-emoji-code-vyv-evans/
3.
Horwitz  LI, Moriarty  JP, Chen  C,  et al.  Quality of discharge practices and patient understanding at an academic medical center.   JAMA Intern Med. 2013;173(18):1715-1722. doi:10.1001/jamainternmed.2013.9318PubMedGoogle Scholar
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Stonbraker  S, Porras  T, Schnall  R.  Patient preferences for visualization of longitudinal patient-reported outcomes data.   J Am Med Inform Assoc. 2020;27(2):212-224. doi:10.1093/jamia/ocz189PubMedGoogle ScholarCrossref
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Hall  L, Hume  C, Tazzyman  S. Five degrees of happiness: effective smiley face Likert scales for evaluating with children. In: Proceedings of the 15th International Conference on Interaction Design and Children (IDC ’16). Association for Computing Machinery; 2016:311-321. doi:10.1145/2930674.2930719
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Phelps  EA, Ling  S, Carrasco  M.  Emotion facilitates perception and potentiates the perceptual benefits of attention.   Psychol Sci. 2006;17(4):292-299. doi:10.1111/j.1467-9280.2006.01701.xPubMedGoogle ScholarCrossref
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Garra  G, Singer  AJ, Taira  BR,  et al.  Validation of the Wong-Baker FACES Pain Rating Scale in pediatric emergency department patients.   Acad Emerg Med. 2010;17(1):50-54. doi:10.1111/j.1553-2712.2009.00620.xPubMedGoogle ScholarCrossref
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Emoji trend report 2019. Adobe. July 2019. Accessed December 2020. https://www.slideshare.net/adobe/adobe-emoji-trend-report-2019/1
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    1 Comment for this article
    Universal Symbols, Not Emoji
    Hugh Williams, MBA, BN | Private
    I suggest the term 'Emoji' is a current fashionable term used to describe pictographic symbols embedded in text. Universal symbols have the advantage of being understandable across all language groups, eg the no entry symbol / not allowed symbol (red circle with a red diagonal line). I suggest, to be successful, any symbol should be universally recognisable, including by people with little or no medical knowledge. For example the picture of a liver could be mistaken for bicycle seat whereas the PQRS wave would be recognisable in most Western cultures.
    CONFLICT OF INTEREST: None Reported
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