After spending much of last week at the Premier healthcare alliance's 2011 Breakthroughs Conference in Nashville, I'm newly impressed with the current eagerness of hospitals and other providers to experiment with clinical integration, health IT and population health in the post-reform era. There's a twist, though—much of the innovation I saw on display is occurring outside of the federal programs of the last several years that were designed to encourage that experimentation.

In other words, hospitals may be wary of the fine print of Medicare's accountable care organization pilot, and many providers with sophisticated EHRs took a pass on attesting for the first round of meaningful use funding, but there's a tremendous hunger to experiment with clinical integration and care coordination beyond the four walls of a hospital.

For instance, take AtlantiCare, a health system based in southeastern New Jersey. I caught up with AtlantiCare's CIO, Christopher Scanzera, between sessions in Nashville. AtlantiCare is taking a pass on both the ACO pilot and the first chance to attest for meaningful use for this year, but they're spearheading a major initiative to link the system with local physician practices, and they have begun working with their employees on a wellness program designed to become a model for the entire system. Other efforts include the possible development of an e-portal that would link patients up with access to their personal health records and other clinical information, and a partnership with UNITE-HERE Local 54, which represents casino workers in nearby Atlantic City, on a population health initiative. Scanzera discussed these efforts in the context of building a future health system that centers around population health and wellness, with less emphasis on acute care and more on community-based prevention.

To be sure, health care conferences draw energized crowds of early adopters, innovators and hospitals that want to learn from them. Still, the sense I get informally is that most hospitals are feeling pressure from all sides—from payment pressures to predictions that acute care services are likely to give way for more community-based care and telemedicine in the years to come. The talk that Highmark, Pennsylvania's largest insurer, is considering acquiring West-Penn Allegheny Health System was referenced by several speakers and attendees as a watershed moment in health care, and one that suggests that all health care players are embracing new arrangements in an uncertain time. Increasingly, hospitals seem to be embracing that new reality with locally informed, forward-looking initiatives that don't necessarily rely on federal encouragement to make a go of it.