At Michigan Medicine, clinicians aren’t supposed to use symbols in medical records. So it came as a surprise to researchers when a survey of the health system’s electronic medical records found thousands of emoji in messages to patients, visit summaries, and post-visit instructions.
Most were in the smiley lexicon — 😊 topped the list of common emoji — while others, like 👁️ and 💊, might map to symptoms or treatments. Still others were more inscrutable.
Emoji use is still rare in clinical records. In a study published Wednesday in JAMA Network Open, the Michigan researchers found that between 2020 and 2024, fewer than two notes in every 100,000 included them. But that may be changing: By the last quarter of 2025, the researchers found emoji in more than 10 notes per 100,000.
That raises questions about whether emoji use in clinical records could impact patient understanding, perceived professionalism, and even legal liability. On Michigan Medicine’s health information management team, “they don’t want symbols used because maybe people can’t interpret them properly,” said Michigan clinical informaticist and the study’s lead author David Hanauer.
In other words, emoji could present risk to patients. But could they also meaningfully add to medical communication?
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“A lot of the emoji seem to be supporting human communication — giving it emotion, giving it context,” said Shuhan He, an emergency medicine physician at Massachusetts General Hospital who co-invented the emoji for the anatomic heart and lung and an emoji-based pain assessment scale. “It’s conveying those ideas that can’t be communicated through your words.”
Because of the difficulty in interpreting an emoji’s intended meaning, the Michigan researchers didn’t dive into the nuance of each symbol’s use in their study. Why was 👥 the ninth most common emoji? 🤷. Another mystery: 🍁, which came in sixth with 382 uses.
Colin Halverson, a bioethicist at Indiana University who did a deep dive into the world of emoji in clinical texts in 2023, posited a guess: The maple leaf could be standing in for a marijuana leaf (cannabis is legal for recreational and medical use in Michigan). “It’s hard to pin down intention behind emoji use, because they’re not standardized in the way that natural languages are,” said Halverson.
The top 50 emoji found in Michigan Medicine’s electronic health records.Hanauer DA et al/JAMA Network Open
That is likely a reason why emoji are uncommon in electronic health records, even though the introduction of Unicode has made them much easier for physicians to include. In surveys of clinicians’ attitudes toward emoji, Halverson has found that many have concerns: They felt emoji were unprofessional, and were worried about their legal implications. (There have been substantive legal issues related to the interpretation of emoji, said Halverson, though not to his knowledge in medicine.)
Some of the clinical teams he surveyed had tried to establish more concrete definitions for certain emoji: In a text chain between clinicians, a 👍 needs to mean “I agree to execute this plan,” not just “I saw this,” or “I think that’s a good idea.”
The Michigan Medicine analysis focused exclusively on emoji in the medical record, not clinician texts, and found that about 41% of them were likely part of a template. Symbols like 📍 and 📞 might frequently end up as formatting in a bulleted list of instructions, for example, or summary notes from a telephone encounter. But others appeared to convey more meaning, and the majority of emoji were found in messages sent to patients.
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Overall, 60% of the system’s emoji indicated an emotion (😕, 😬, 😉) while the rest were informational or symbolic (🚫, 🩺, 👟). To Hanauer, the emotional emoji raised the biggest concerns.
“The nuance between each one is really small,” he said. “It can be really difficult to understand, especially with all the faces, what do they all mean?” Different age groups could interpret emoji differently, and the researchers found patients of all ages with emoji in their records. In fact, the second-largest age group of recipients was between 70 and 79. The study didn’t analyze the age or the role of the health care provider who introduced the emoji into the record, something Halverson would like to learn.
After seeing the results, the Michigan health information team doubled down on its anti-symbol policy, telling Hanauer they would clarify it includes a ban on emoji.
“It does raise a question: Is that the right thing to do? And I don’t have the answer to that,” said Hanauer. “Should they not be added, or should people be allowed to add them because they are being used more and more now for informal communication?”
To answer that question, Hanauer hopes that more health systems will take a look to see how their clinicians are using emoji and how patients are interpreting them. They can be in hiding, he said: In Michigan’s Epic EHR, the process of moving records to the database that enables medical research strips out all the emoji in a clinical note. “Anybody who’s going to use that standard system for looking for emojis, they’ll never find them,” he said.
“There’s a lot of emerging work in this area, and part of it is just first having the basic understanding of how often [emoji] are used in studies like this,” said He. “I think over the next 10 years, we’re going to see a lot better understanding.”
For now, the medical establishment is still iffy on emoji — and not just at health systems. When he submitted his paper in 2023, said Halverson, JAMA nixed his original emoji-fortified title: “When words are not enough: Content analysis of emoji use in clinical texting systems 👩⚕️ 👨⚕️ 📱.”