Build vs buy in telemedicine is best understood as a decision made per layer of the platform, not once for the whole product. The major layers each have their own answer: real-time video transport (an open-source SFU like mediasoup or LiveKit you operate yourself, versus a CPaaS you rent), EHR connectivity (a direct integration versus an aggregator), e-prescribing (a certified partner — almost always bought, because the certification and controlled-substance requirements are prohibitive to build), and AI features (a hosted API versus self-hosted models). A mature platform is usually a deliberate mix, not all-build or all-buy.
The deciding variables are consistent across layers. Build what genuinely differentiates you and buy the commodity plumbing. Weigh the unit economics at your actual scale, not at launch. Confirm that any vendor handling PHI will sign a business associate agreement (BAA) covering the specific configuration you will use. And be honest about the engineering you can sustain — not just ship once, but operate, patch, and keep reliable for years, because owning an open-source media server means owning its operational burden permanently.
The most common and expensive mistake is treating the decision as permanent. CPaaS economics that are clearly cheaper than building at 1,000 visits a month often invert at 100,000, where per-minute pricing dwarfs the cost of running your own infrastructure — and conversely, building too early can sink a young team in operational work it cannot afford. Revisit each layer's decision at defined scale milestones, and design interfaces so that swapping a bought component for a built one later is a contained project rather than a rewrite.
