End-to-end encryption (E2EE) means that only the endpoints of a conversation — the participants' own devices — can decrypt the media. No server in the path can read it, and that includes your own infrastructure: a Selective Forwarding Unit (SFU), the media server that routes video between participants, sees only ciphertext. In WebRTC, the browser-based real-time media stack, transport is already encrypted hop-by-hop with DTLS-SRTP; E2EE is layered on top of that, typically using insertable frame encryption or a group-key scheme based on Messaging Layer Security (MLS), so the keys never reach the server.
The reason this matters to a telemedicine team is that E2EE collides directly with features that assume the server can read media. Server-side recording, live captions, AI scribes, and automated quality monitoring all depend on decrypting the stream centrally — under true E2EE they break, or must be redesigned to run at the endpoints, which is harder and limits scale. So E2EE is a deliberate architectural trade, not a default to switch on everywhere.
A point teams frequently get wrong: HIPAA does not require E2EE. The Security Rule's encryption requirement (45 CFR §164.312) is satisfied by strong encryption in transit and at rest, which WebRTC's DTLS-SRTP plus encrypted storage already provides. E2EE answers a stronger threat model — one where the server operator itself is not trusted to see content, such as highly sensitive behavioral-health or VIP scenarios. Choose it for that reason explicitly, and document which features you are giving up, so that a later request for server-side recording does not quietly undermine the guarantee you promised patients.
