The emoji symbols on our phones, tablets and computers are so ubiquitous, some worry they’re helping to destroy language. Others argue that emojis should be an accepted language of their own, a universal, inclusive and simple mode of communication. Many doctors say those same benefits can improve how they care for patients.
Since 2010, more than 3,600 emoji have been adopted by the Unicode Consortium, the Silicon Valley nonprofit group that oversees the processing and storage of technical symbols and punctuation used in digital text, including emojis. This year, a small team of doctors and major kidney organizations are lobbying the Consortium to add a medically accurate kidney emoji to the Unicode Standard.
Their many months of research have included discussion about what an immediately recognizable, yet fun and unintimidating kidney emoji should look like. Would including the blood vessels be too gory, or unclear in emoji size? Should it depict one kidney or the pair? Would the average person even know what the brownish-pink blob suddenly on their emoji keyboard is supposed to be?
“Health literacy around the kidney is quite poor,” says Caitlyn Vlasschaert, an internal medicine resident and PhD student in nephrology at Queen’s University in Ontario, Canada. “One in 10 people around the world has kidney disease, but 90 percent don’t know they have it.”
Studies of patients with kidney disease suggest many were unaware of the basic functions of kidneys, such as helping the body get rid of waste. A kidney emoji on everyone’s phones could inspire people to think more about their kidney health and also normalize talking about kidney disease, if they’re one of the 850 million people worldwide who have it, Vlasschaert says.
It might sound odd that providing a faster, visual way to text friends “whats up with ur kidney?” would be a pressing concern in the medical community. But it’s part of a vigorous national campaign for medically accurate emojis that could help improve communication between doctor and patient and ultimately improve care, proponents argued in a commentary published in the Journal of the American Medical Association in the fall.
“How we measure the subtleties in patient outcomes to understand how people feel is something we’ve been struggling with for a long time,” says one of those advocates, Harvard Medical School instructor Dr. Shuhan He, an emergency department physician at Massachusetts General Hospital and the director of growth at its Center for Innovation in Digital HealthCare.
Children, particularly those who are nonverbal or have a disease that hinders their ability to communicate, would benefit from a visual system like emojis to help articulate their pain, he says. During in-person visits, doctors already commonly use the Wong-Baker FACES pain scale, a system of cartoon faces ranging from happy and content to crying and anguished, developed in the 1980s. Expanding the use of visual scales that are standardized and digitized for patients’ electronic medical records could help doctors understand their patients’ conditions and whether they’re improving over time.
Emojis in the exam room
Most modern electronic medical records are shifting to unicode anyway, so emojis are actually already part of most electronic medical records.
“It’s not a technical issue, but rather a scientific validation one,” Dr. He says. More research is needed to establish that emojis are just as valid and reliable a pain scale as describing pain to a doctor or rating pain on a scale of one to 10.
If the kidney and other medical emojis are approved and integrated into electronic medical records, doctors could use and record emoji shared by patients via text, email, telehealth appointments and online patient portals.
“The ability to ask the fundamental question ‘How do you feel?’ in a scientific way is really relatively new in health care,” Dr. He adds.
The Affordable Care Act has contributed to this shift because its programs aim to incentivize quality of care, while reducing its costs. Emojis could help doctors monitor patients’ mental well-being as well, and might be particularly useful for patients who aren’t comfortable articulating emotions. Chronic conditions such as fibromyalgia and arthritis, for example, can increase risk for depression, so it’s important for doctors to be aware of changes or declines in mental health.
A study published in 2019 suggested that emojis accurately identified symptoms of depression in more than 400 young adults. Other studies suggest emojis might be an effective tool to help patients manage their health. In a 2020 study of English- and Spanish-speaking people, most with low health literacy, researchers concluded that a bar graph combined with emojis was participants’ preferred format and the easiest for them to understand.
In 2018, the authors of a paper published in the Journal of Oncology concluded that emojis were a comprehensible, reliable measurement of patient-reported outcomes in a study of cancer patients, even for people with low health literacy. Of the 75 patients who completed the study, 92 percent reported they would use emoji scales again and 89 percent would recommend that others use emoji scales.
And emojis also have the power to easily connect generations: Reece and Olivia Ohmer, two high school students and sisters in Michigan with diabetes, developed a prototype emoticon system to make communicating with their parents about management of the condition “less annoying.”
The trouble with organs
Despite evidence suggesting emoji could help improve patient care, Dr. He and his colleagues might have trouble getting their organs (future emoji goals include a stomach, liver and intestine) approved by the Unicode Consortium. Applicants need to satisfy several criteria in their emoji applications, which are more involved than you might think.
The Consortium accepts emoji applications in the spring and approves around 60 a year, announcing new additions in September. One reason for the cautious approach is that vendors want limits on the number of emoji in the system; the more emoji there are, the more computer memory is required to load them. Applicants for new emoji need to demonstrate demand, evidenced by Google search results. The proposed emoji needs to have a broad scope. And in this instance, the group needs to show there isn’t an emoji that could already represent a kidney.
Because emojis are expected to be multipurpose, it might be difficult to get very specific, straightforward organs approved, says cognitive scientist Neil Cohn, PhD, associate professor at the Tilburg Center for Cognition and Communication at Tilburg University in the Netherlands and author of The Visual Narrative Reader.
“The most effective emoji don’t have just one specific meaning,” Cohn says. “That may conflict with medical use.”
Also, even seemingly straightforward images might not be understood as intuitively as some like to think.
“Pictures are not a universal communication system,” says Cohn. “It might be simple, rapid learning, but they require learning. The idea that they’re universal comes from people who’ve already done that learning.”
Picturing the future
Despite the hurdles, in 2018, members of the medical community successfully lobbied to add an anatomically correct brain emoji. And approval of heart and lung emojis were granted in 2019. It still might be an uphill battle for more obscure organs, Cohn says.
Alternatively, the medical community could just develop its own app and include any emoji they want, without having to fight for approval from the Consortium. What’s stopping them? Dr. He says that wouldn’t be practical.
For instance, the National Institutes of Health has already developed keyboards of hundreds of reliable and evidence-based visual analogue scales. “The issue is that the lack of standardization means no particular scale gets significant uptake, and they all become trademarked and copyrighted,” says Dr. He, “so it’s difficult to share them, versus an open access tool like emoji.”
Right now, there are a few studies underway examining emoji efficacy scales of pain in every medical setting, such as emergency rooms and intensive care units. Researchers are also testing emoji’s ability to capture the quality of patients’ pain, such as whether it feels more dull and throbbing, for example, or sharp and fiery.
Vlasschaert and her colleagues think they have a good shot at winning approval for their kidney emoji application, which they’ll submit in April. Dr. He simply disagrees with skeptics who don’t see much use for it.
“I find it odd that there can be a potable water sign, but no kidney emoji,” Dr. He says, referencing the 850 million people living with kidney disease. “If you were someone who was on the kidney transplant list, or had renal cell cancer, one of the top 10 most commonly diagnosed cancers, wouldn’t this be the most important emoji on the keyboard to you?”