Emojis and Why Understanding Health Information Is So Difficult

Craig Joseph, MD
By: Craig Joseph, MD
Date: May 13, 2020

emojisI’ve been accused of being a geek. I’m not sure why. But anyway, last week I was listening to a podcast about emojis. You know – emojis (or emoji if you prefer that as the plural): those cute little cartoony characters that are typically used in texts to convey meaning. Instead of texting the words “Thanks so much,” you can simply text 🙏. In fact, it’s possible to string together a complete dialog with a series of emojis. Imagine that some patients get a 🦠 and have to take an 🚑 to go to the 🏥. There, the patient is taken care of by a 👩‍⚕️ and hopefully they’ll get better and go home following safe practices and looking like 😷.

Emojis are a pretty cool way to say a lot with a few characters. Back in the day, companies like Apple, Google, Microsoft, and Samsung produced their own emoji art and the supporting technology, and those worked great if messaging within the same vendor (i.e. iPhone to iPhone.) But it was not pretty if trying to communicate from an iPhone to an Android device. This chaos and disorder was ultimately brought under control by the Unicode Consortium (NB: future AP World History test question, I predict!) Unicode now dictates what is and what is not an emoji. Every vendor gets to make their own artwork, but the intent and title of the emoji is tightly controlled.

If you want to see the list of all possible emojis, there’s only one place to go: Emojipedia, of course. The folks at the Emojipedia website have a searchable database so you can learn more than you probably wanted to about the differences between 🚴, 🚵, and 🚲. While all of this organization and precision is great, there are still problems. People can interpret the same emoji in vastly different ways. Most (ok, some) of us know that the eggplant emoji is hardly ever used to discuss an eggplant. The brilliance of emojis is that they mean whatever we want them to mean.

While I think we all know much more about emojis than we did before, how are they related to understanding medical information? I’m glad you asked. Much like with emojis, terms that we use in healthcare are often interpreted in different ways by different audiences. While it may seem like only doctors, nurses, and other clinicians need to use and understand healthcare terminology, nothing could be further from the truth. There are non-medical audiences to our notes and documentation. We’ve got lawyers, insurance companies, state and federal government agencies, and private regulatory companies; the list goes on and on. These folks sometimes assign their own meaning to certain words. For example, when I was a pediatric resident a million years ago, I was taught that if I documented that a baby had a fever and was “agitated”  that I had better describe the findings of the spinal tap in the next sentence. While “agitated” meant one thing to me, it meant something entirely different to malpractice attorneys.

It’s not just non-clinical audiences that have to be considered. Certain terms and many abbreviations mean completely different things to different physicians. While we are asked to use abbreviations much less frequently with the advent of the electronic health record (EHR), old habits die hard. “ROM” means range of motion to an orthopedic surgeon, rupture of membranes to an obstetrician, and right otitis media (i.e. middle ear infection) to a pediatrician. Context makes it difficult to confuse these terms, yet you can see how interpretation requires some work.

To make things worse, in American healthcare, we don’t have an equivalent to the Unicode Consortium. There is no one end all, be all authority that sets the meaning of medical terms of art. We have standardized code sets; we have lots of standardized code sets (e.g. ICD-10, CPT, HCPCS, SNOMED, LOINC, etc.) But there is no governing authority to define ROM or tell us how we’re supposed to treat an agitated (or fussy or cranky) infant.

It’s not just the definition of terms that are troublesome. We struggle to agree on how we classify “buckets” of information. While we are using paper or an EHR, there are typically sections for a problem list or a past medical history. To some (including yours truly), these should be mutually-exclusive lists (i.e. if you have diabetes mellitus now, it should be on your problem list. If you had bariatric surgery and no longer have diabetes mellitus, it should be in your past medical history). Others see these terms as synonymous, and use these sections of the chart in unique ways. While arguments can be made for both practices, without consensus or a “higher authority,” it’s difficult to know or predict what information should be where.

It’s clear that we have some work to do if we want to more easily understand and share clinical information. Perhaps we need a 🧑‍⚖️ to tell us what terms mean and where they go in the medical record, but many 👨‍⚕️ and 👩‍⚕️ won’t be 🙂 with that. Today it’s a 🧩 to interpret the medical record, but as we work to achieve consensus, we’ll meet our 🥅.

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