Background: As more and more cardiology centres are moving towards cineless digital cath labs, this development creates an excellent opportunity for the cardiology centres to exchange cardiac images electronically with other cardiology centres. However, electronic transfer of this privacy-sensitive information also creates potential security problems.Methods: A computer application has been developed to exchange cardiac images between different hospitals. The transported image files are encrypted with the DES/RSA algorithm, the industry standard for data-encryption. However, key management has turned out to be a weak spot of the RSA private/public key encryption method. Therefore in our application smart cards are used to store the RSA private key. In this way the encryption-key management problem can be solved adequately.Experiences: RSA/DES encryption using smart-card technology has already been successfully implemented as an adequate solution in many banking/money transfer applications. This technique could easily be added to our cardiac image exchange application, since it requires no specific hardware except for a standard smart-card reader. Private key distribution with smart-cards has proven to be simple and safe. An additional benefit of the RSA/DES implementation with smartcards is that an electronic signature can be added to each message. The use of smartcards fits also nicely in the existing ideas for an overall security setup in the medical field in the Netherlands.Conclusion: The electronic highway can very well serve as carrier for the exchange of cardiac images between cardiology centres and cardiologists at home. The need to do this in a secure way can be fulfilled by using RSA/DES encryption in combination with smart card technology. This approach is especially strong because it supports a very safe way for the key management policy that can be very well embedded into existing security approaches in hospital organisations.